Basic Information
| Provider Information | |||||||||
| NPI: | 1477667004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORAH | ||||||||
| FirstName: | JOEY | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 714328 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432714328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402055800 | ||||||||
| FaxNumber: | 4402055801 | ||||||||
| Practice Location | |||||||||
| Address1: | 9485 MENTOR AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440604597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402055800 | ||||||||
| FaxNumber: | 4402055801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35088236 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2701302 | 05 | OH | MEDICAID |