Healthcare Provider Details

I. General information

NPI: 1699834390
Provider Name (Legal Business Name): GEAUGA SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E WASHINGTON ST
AUBURN OH
44023
US

IV. Provider business mailing address

11800 E WASHINGTON ST
AUBURN OH
44023
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-6452
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL KELLIS
Title or Position: PRESIDENT
Credential: DO
Phone: 440-285-1796