MEDICARE: DR. JOANN KRIVETZKY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	35072306K	OH
2	207VG0400X	Gynecology Physician	35-072306K	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1790070191	OTHER		GROUP NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922017607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOANN KRIVETZKY MD

Provider Business Mailing Address
First Line	:	4256 FULTON DR NW
Second Line	:	STE B
City	:	CANTON
State	:	OH
Zip	:	44718-2879
Country	:	US
Telephone Number	:	330-546-0751
Fax Number	:	330-956-5237

Provider Business Practice Location Address
First Line	:	4256 FULTON DR NW
Second Line	:	STE B
City	:	CANTON
State	:	OH
Zip	:	44718-2879
Country	:	US
Telephone Number	:	330-546-0751
Fax Number	:	330-956-5237

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	05/24/2012

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