Healthcare Provider Details

I. General information

NPI: 1083745467
Provider Name (Legal Business Name): ALLEN J PASSERALLO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

6560 DUNEDEN AVE
SOLON OH
44139-4046
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-2200
  • Fax:
Mailing address:
  • Phone: 440-498-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAT00321
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: