1639318413 NPI number — EVERGREEN PAIN MANAGEMENT & REHABILITATION LTD

Table of content: (NPI 1639318413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639318413 NPI number — EVERGREEN PAIN MANAGEMENT & REHABILITATION LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN PAIN MANAGEMENT & REHABILITATION LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639318413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5445 DETROIT RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SHEFFIELD VILLAGE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44054-2904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-240-9111
Provider Business Mailing Address Fax Number:
440-934-5459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5445 DETROIT RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SHEFFIELD VILLAGE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44054-2904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-240-9111
Provider Business Practice Location Address Fax Number:
440-934-5459
Provider Enumeration Date:
02/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
440-240-9111

Provider Taxonomy Codes

  • Taxonomy code: 111NX0100X , with the licence number:  2954 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2085032 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 123236700 . This is a "FEDERAL WORKER'S COMPENSATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000324155 . This is a "BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".