Healthcare Provider Details

I. General information

NPI: 1366514317
Provider Name (Legal Business Name): ROMAN HANYCZ P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 ROCKSIDE RD SUITE 103
INDEPENDENCE OH
44131-2358
US

IV. Provider business mailing address

PO BOX 932127
CLEVELAND OH
44193-0008
US

V. Phone/Fax

Practice location:
  • Phone: 216-369-2800
  • Fax:
Mailing address:
  • Phone: 216-369-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50000489
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: