Healthcare Provider Details

I. General information

NPI: 1730779802
Provider Name (Legal Business Name): ILYA VAISBERG CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 11/06/2023
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

IV. Provider business mailing address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

V. Phone/Fax

Practice location:
  • Phone: 216-778-7800
  • Fax:
Mailing address:
  • Phone: 330-480-3258
  • Fax: 330-480-4119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0027287
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0027287
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: