Healthcare Provider Details

I. General information

NPI: 1336426279
Provider Name (Legal Business Name): OHIO PERMANENTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7536 FREDLE DR
CONCORD TWP OH
44077-9406
US

IV. Provider business mailing address

12301 SNOW RD
PARMA OH
44130-1002
US

V. Phone/Fax

Practice location:
  • Phone: 216-265-8844
  • Fax: 216-265-8890
Mailing address:
  • Phone: 216-265-8844
  • Fax: 216-265-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0211372
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: MR. CRAIG FAERBER
Title or Position: VP/CFO
Credential:
Phone: 216-265-8844