Healthcare Provider Details

I. General information

NPI: 1376911495
Provider Name (Legal Business Name): GEAUGA MEDICAL THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2015
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13170 RAVENNA RD SUITE 108
CHARDON OH
44024-7025
US

IV. Provider business mailing address

125 W MCDOWELL RD SUITE A
PHOENIX AZ
85003-1223
US

V. Phone/Fax

Practice location:
  • Phone: 440-409-7055
  • Fax: 440-279-4009
Mailing address:
  • Phone: 855-360-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number35.122879
License Number StateOH

VIII. Authorized Official

Name: DR. ZAID FADUL
Title or Position: CEO
Credential: MD
Phone: 855-360-4673