Basic Information
| Provider Information | |||||||||
| NPI: | 1528084431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CG ENDOSCOPY CENTER LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3722 DRESSLER RD NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304794232 | ||||||||
| FaxNumber: | 3304775805 | ||||||||
| Practice Location | |||||||||
| Address1: | 3722 DRESSLER RD NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304794232 | ||||||||
| FaxNumber: | 3304775805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | SCHIRACK | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3304794232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 0665AS | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 2321759 | 05 | OH | MEDICAID |