Basic Information
| Provider Information | |||||||||
| NPI: | 1528002490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHAGRIN VALLEY ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3755 ORANGE PL STE 105 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650358 | ||||||||
| FaxNumber: | 2167650378 | ||||||||
| Practice Location | |||||||||
| Address1: | 3755 ORANGE PL STE 102 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650358 | ||||||||
| FaxNumber: | 2167650378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2167650358 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2529660 | 05 | OH | MEDICAID |