1518105519 NPI number — GERIATRIC PHYSICIAN ASSISTANTS LLC

Table of content: (NPI 1518105519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518105519 NPI number — GERIATRIC PHYSICIAN ASSISTANTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERIATRIC PHYSICIAN ASSISTANTS 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:
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:
1518105519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3843 SAVOY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRVIEW PARK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44126-1719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-506-3058
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
842 CORPORATE WAY
Provider Second Line Business Practice Location Address:
SUITE 850
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-1537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-871-4700
Provider Business Practice Location Address Fax Number:
440-871-4702
Provider Enumeration Date:
01/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
IRAVANI
Authorized Official First Name:
MOHAMMAD
Authorized Official Middle Name:
REZA
Authorized Official Title or Position:
OWNER/PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
440-506-3058

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  50001923 , 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)





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