Basic Information
Provider Information | |||||||||
NPI: | 1871587246 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KINDWALL- KELLER | ||||||||
FirstName: | TAMILA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 METROHEALTH DR | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441091900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2167787800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 METROHEALTH DR | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441091900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2167787800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2005 | ||||||||
LastUpdateDate: | 05/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | 34.007582 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0000X | 0102202838 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X | 34.007582 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 363704 | 01 | OH | WELLCARE | OTHER | 7001627 | 01 | OH | AETNA | OTHER | 730908 | 01 | OH | BUCKEYE | OTHER | 64086093 | 05 | KY |   | MEDICAID | 000000539573 | 01 | OH | ANTHEM | OTHER | 200485360 | 05 | IN |   | MEDICAID | 2489196 | 05 | OH |   | MEDICAID | 000000224462 | 01 | OH | UNISON | OTHER | P00432049 | 01 |   | RAILROAD MEDICARE | OTHER |