Healthcare Provider Details

I. General information

NPI: 1982685541
Provider Name (Legal Business Name): PREM S. JAWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE/Q10-1 GLICKMAN UROLOGICAL & KIDNEY INSTITUTE
CLEVELAND OH
44195
US

IV. Provider business mailing address

9500 EUCLID AVE/Q10-1 GLICKMAN UROLOGICAL & KIDNEY INSTITUTE
CLEVELAND OH
44195
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-0221
  • Fax: 216-636-4492
Mailing address:
  • Phone: 216-444-0221
  • Fax: 216-636-4492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35037561J
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35-03-7561J
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: