Basic Information
| Provider Information | |||||||||
| NPI: | 1447233762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KESHOCK | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOEHM | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 860 E BROAD ST | ||||||||
| Address2: | SUITE I | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440356542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403238458 | ||||||||
| FaxNumber: | 4403237900 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 E RIVER ST | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440355902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403297500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35066027 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0169053 | 05 | OH | MEDICAID |