Healthcare Provider Details

I. General information

NPI: 1457452997
Provider Name (Legal Business Name): THOMAS WASSERBAUER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29099 HEALTH CAMPUS DR STE 180
WESTLAKE OH
44145-5299
US

IV. Provider business mailing address

PO BOX 74620
CLEVELAND OH
44194-0703
US

V. Phone/Fax

Practice location:
  • Phone: 216-383-0100
  • Fax: 216-383-6481
Mailing address:
  • Phone: 216-383-6480
  • Fax: 216-383-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35030940W
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: