Basic Information
| Provider Information | |||||||||
| NPI: | 1477555407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROY | ||||||||
| FirstName: | CHAITY | ||||||||
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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: | 850 COLUMBIA RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441451493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408084000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 04/28/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 67000098 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2384058 | 05 | OH | MEDICAID |