Basic Information
Provider Information | |||||||||
NPI: | 1891942579 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH OHIO GASTROENTEROLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30701 CLEMENS ROAD | ||||||||
Address2: |   | ||||||||
City: | WESTLAKE | ||||||||
State: | OH | ||||||||
PostalCode: | 441451493 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4406171212 | ||||||||
FaxNumber: | 4406171213 | ||||||||
Practice Location | |||||||||
Address1: | 30701 CLEMENS ROAD | ||||||||
Address2: |   | ||||||||
City: | WESTLAKE | ||||||||
State: | OH | ||||||||
PostalCode: | 44145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4406171212 | ||||||||
FaxNumber: | 4406171213 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2008 | ||||||||
LastUpdateDate: | 08/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOESINGER | ||||||||
AuthorizedOfficialFirstName: | PETRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4406171212 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   | 174400000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.