1902976699 NPI number — J&K PAIN MANAGEMENT COMPANY LLC

Table of content: (NPI 1902976699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902976699 NPI number — J&K PAIN MANAGEMENT COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J&K PAIN MANAGEMENT COMPANY LLC
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:
GREAT LAKES PAIN MANAGEMENT
Provider Other Organization Name Type Code:
3
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:
1902976699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2760 SOM CENTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOUGHBY HILLS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-306-2358
Provider Business Mailing Address Fax Number:
440-306-2359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2760 SOM CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLOUGHBY HILLS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-306-2358
Provider Business Practice Location Address Fax Number:
440-306-2359
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIKHAIL
Authorized Official First Name:
EMAD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
440-306-2358

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  35075570-M , 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: 2083810 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 736496 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: C75570 . This is a "SUMMA CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 352308 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7813229 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 8076384 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000389088 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2124534 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00304928 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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