Healthcare Provider Details

I. General information

NPI: 1538126693
Provider Name (Legal Business Name): WESTERN RESERVE PROFESSIONAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 CURRIE HALL PKWY STE D
KENT OH
44240-4387
US

IV. Provider business mailing address

PO BOX 951971
CLEVELAND OH
44193-0021
US

V. Phone/Fax

Practice location:
  • Phone: 330-548-0086
  • Fax: 330-548-0085
Mailing address:
  • Phone: 330-548-0080
  • Fax: 330-548-0085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY ANN SEMANCIK
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 330-548-0080