Healthcare Provider Details

I. General information

NPI: 1033247697
Provider Name (Legal Business Name): MISS MARY ELIZABETH KOGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3717 BARLETT STREET
CLEVELAND OH
44128-4806
US

IV. Provider business mailing address

19200 ROSELAND AVE G-349
EUCLID OH
44117-1385
US

V. Phone/Fax

Practice location:
  • Phone: 216-751-5176
  • Fax:
Mailing address:
  • Phone: 216-624-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number320922870804
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: