Provider Demographics
NPI:1679598163
Name:KNEISLEY, ROBERT EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:KNEISLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:247 S BURNETT RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2639
Mailing Address - Country:US
Mailing Address - Phone:937-328-8850
Mailing Address - Fax:937-328-8860
Practice Address - Street 1:247 S BURNETT RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2639
Practice Address - Country:US
Practice Address - Phone:937-328-8850
Practice Address - Fax:937-328-8860
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35042766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35-042766OtherOHIO LICENSE
OH037-48-67Medicaid
OH1679598163OtherNPI
OHAK8398326OtherDEA
OHAK8398326OtherDEA
OH35-042766OtherOHIO LICENSE