Provider Demographics
NPI:1952513277
Name:KSENICH, NICHOLAS J (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:KSENICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-989-3801
Mailing Address - Fax:440-960-0264
Practice Address - Street 1:1120 E BROAD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6306
Practice Address - Country:US
Practice Address - Phone:440-365-2600
Practice Address - Fax:440-365-5543
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061954207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OH0868173Medicaid
OH3025372Medicaid
OHE97284Medicare UPIN
OH9389631Medicare PIN