Basic Information
| Provider Information | |||||||||
| NPI: | 1427041714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENENDEZ | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 567 | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440220567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164645160 | ||||||||
| FaxNumber: | 2164645982 | ||||||||
| Practice Location | |||||||||
| Address1: | 29017 CEDAR RD | ||||||||
| Address2: | |||||||||
| City: | LYNDHURST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441244073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404608000 | ||||||||
| FaxNumber: | 4404601759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 12/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 67000018 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1427041714 | 05 | MI | MEDICAID | 000000515970 | 01 | OH | ANTHEM | OTHER | 415010 | 01 | OH | WELLCARE MEDICAID | OTHER | 0583328 | 01 | OH | BCMH | OTHER | 2491021 | 05 | OH | MEDICAID | 7405896 | 01 | OH | AETNA | OTHER | P00405856 | 01 | OH | MEDICARE RAILROAD | OTHER | 000000232169 | 01 | OH | UNISON | OTHER |