Healthcare Provider Details

I. General information

NPI: 1598750705
Provider Name (Legal Business Name): JEROME NGANGANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29000 CENTER RIDGE RD ST JOHN WEST SHORE HOSPITAL
WESTLAKE OH
44145-5293
US

IV. Provider business mailing address

30680 BAINBRIDGE RD NORTHEAST OHIO GROUP PRACTICE
CLEVELAND OH
44139-2282
US

V. Phone/Fax

Practice location:
  • Phone: 440-835-8000
  • Fax:
Mailing address:
  • Phone: 440-542-5023
  • Fax: 440-542-5029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35073902
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: