Healthcare Provider Details

I. General information

NPI: 1578663951
Provider Name (Legal Business Name): SANJEEV K. BHAVNANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9293 STATE ROUTE 43 STE B
STREETSBORO OH
44241-5376
US

IV. Provider business mailing address

9293 STATE ROUTE 43 STE B
STREETSBORO OH
44241-5376
US

V. Phone/Fax

Practice location:
  • Phone: 330-626-1113
  • Fax: 330-626-1133
Mailing address:
  • Phone: 330-626-1113
  • Fax: 330-626-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number35-079601
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number77555
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35079601
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: