Healthcare Provider Details

I. General information

NPI: 1962495846
Provider Name (Legal Business Name): SARAH RUSSELL AA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106
US

IV. Provider business mailing address

3605 WARRENSVILLE CENTER ROAD 1ST FLOOR
SHAKER HTS OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-7330
  • Fax: 216-844-3781
Mailing address:
  • Phone: 216-286-6260
  • Fax: 216-286-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number67000095
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: