Healthcare Provider Details

I. General information

NPI: 1912094145
Provider Name (Legal Business Name): WESTERN RESERVE PROFESSIONAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6847 N CHESTNUT ST
RAVENNA OH
44266-3929
US

IV. Provider business mailing address

307 W MAIN ST SUITE C
KENT OH
44240-2400
US

V. Phone/Fax

Practice location:
  • Phone: 330-677-3628
  • Fax: 330-677-3626
Mailing address:
  • Phone: 330-677-3628
  • Fax: 330-677-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY SEMANCIK
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 330-677-3628