Healthcare Provider Details

I. General information

NPI: 1508286022
Provider Name (Legal Business Name): COREY GILDEA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E WASHINGTON STREET
MEDINA OH
44256
US

IV. Provider business mailing address

9355 BASSWOOD DR
OLMSTED FALLS OH
44138-2577
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-1000
  • Fax:
Mailing address:
  • Phone: 814-504-1595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.08838
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.002711
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: