Basic Information
| Provider Information | |||||||||
| NPI: | 1902843899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIVAK | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2601 MISSION POINT BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454316600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379124441 | ||||||||
| FaxNumber: | 9374294236 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 BOARDMAN POLAND RD | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445141935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306292300 | ||||||||
| FaxNumber: | 3306292371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34004606S | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0714794 | 05 | OH | MEDICAID | 942460636209 | 01 | OH | CARESOURCE | OTHER | P00220368 | 01 | OH | MEDICARE RR-GA | OTHER |