Healthcare Provider Details

I. General information

NPI: 1912086240
Provider Name (Legal Business Name): WESTERN RESERVE PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 ROCKSIDE RD #640
INDEPENDENCE OH
44131-2194
US

IV. Provider business mailing address

5005 ROCKSIDE RD #640
INDEPENDENCE OH
44131-2194
US

V. Phone/Fax

Practice location:
  • Phone: 216-328-0800
  • Fax: 330-328-1860
Mailing address:
  • Phone: 216-328-0800
  • Fax: 330-328-1860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35051876P
License Number StateOH

VIII. Authorized Official

Name: GEORGE J PICHA
Title or Position: CEO
Credential: MD
Phone: 216-328-0800