Healthcare Provider Details

I. General information

NPI: 1598886053
Provider Name (Legal Business Name): DONNA MARIE HRADISKY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 BERKLEY RD
RICHFIELD OH
44286-9486
US

IV. Provider business mailing address

4921 BERKLEY RD
RICHFIELD OH
44286-9486
US

V. Phone/Fax

Practice location:
  • Phone: 440-567-9125
  • Fax:
Mailing address:
  • Phone: 440-567-9125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number2800
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: