Healthcare Provider Details

I. General information

NPI: 1679574156
Provider Name (Legal Business Name): WEST SIDE CARDIOTHORACIC SURGEONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15644 MADISON AVE SUITE #202
LAKEWOOD OH
44107-5622
US

IV. Provider business mailing address

PO BOX 567
CHAGRIN FALLS OH
44022-0567
US

V. Phone/Fax

Practice location:
  • Phone: 216-521-3384
  • Fax: 216-521-3385
Mailing address:
  • Phone: 216-464-5160
  • Fax: 216-464-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: DR. M. HANI KHADDAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-521-3384