Healthcare Provider Details

I. General information

NPI: 1083243505
Provider Name (Legal Business Name): JERKY EBAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

8055 MAYFIELD RD STE 105
CHESTERLAND OH
44026-2447
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-0288
  • Fax:
Mailing address:
  • Phone: 440-214-8026
  • Fax: 216-201-7963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.153447
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: