1730573965 NPI number — JENNALEE CHAGIN NP

Table of content: JENNALEE CHAGIN NP (NPI 1730573965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730573965 NPI number — JENNALEE CHAGIN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAGIN
Provider First Name:
JENNALEE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1730573965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3420 WOOSTER RD
Provider Second Line Business Mailing Address:
309
Provider Business Mailing Address City Name:
ROCKY RIVER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44116-4174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-207-4121
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 NORTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLMADGE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44278-1925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-344-3990
Provider Business Practice Location Address Fax Number:
330-634-9433
Provider Enumeration Date:
03/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  COA.16982NP , 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: 9338635 . This is a "PARTNERS PHYSICIAN GROUP MEDICARE GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0091231 . This is a "PARTNERS PHYSICIAN GROUP MEDICAID GROUP # - URGENT CARES" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1992138028 . This is a "PARTNERS PHYSICIAN GROUP TYPE 2 NPI # - URGENT CARES" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1164814414 . This is a "PARTNERS PHYSICIAN GROUP TYPE 2 NPI # - HWE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0125272 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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