Healthcare Provider Details

I. General information

NPI: 1669687760
Provider Name (Legal Business Name): WALTER J PASSARELLO, DO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8064 SOUTH AVE
BOARDMAN OH
44512-6153
US

IV. Provider business mailing address

3584 TIMBERBROOKE TRL
POLAND OH
44514-5321
US

V. Phone/Fax

Practice location:
  • Phone: 330-757-7888
  • Fax: 330-757-4912
Mailing address:
  • Phone: 330-757-7888
  • Fax: 330-757-4912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number34006450
License Number StateOH

VIII. Authorized Official

Name: DR. WALTER J PASSARELLO
Title or Position: OWNER
Credential: D.O.
Phone: 330-757-7888