Basic Information
| Provider Information | |||||||||
| NPI: | 1588745632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN RESERVE PROFESSIONAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 W MAIN ST | ||||||||
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| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442402400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773628 | ||||||||
| FaxNumber: | 3306773626 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 DARROW ROAD | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773628 | ||||||||
| FaxNumber: | 3306773626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SEMANCIK | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3306773628 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.