Provider Demographics
NPI:1528073004
Name:BUSDIECKER, KEVIN WAYNE (AA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:BUSDIECKER
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 METRO HEALTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109
Mailing Address - Country:US
Mailing Address - Phone:216-778-5790
Mailing Address - Fax:
Practice Address - Street 1:2500 METRO HEALTH DRIVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109
Practice Address - Country:US
Practice Address - Phone:216-778-5790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67-000036367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH414955OtherWELLCARE MEDICAID
OH000000232158OtherUNISON
OH0583328OtherBCMH
OH9724074OtherAETNA
OH000000515962OtherANTHEM
OH430037559OtherRAILROAD MEDICARE
OH2739264Medicaid
OH2739264Medicaid
OHBU7116141Medicare PIN