=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104965698
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EFIM SCHERBAKOV LMT, LPTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 04/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 83 N MILLER RD STE 104
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-3729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-808-0661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 BROOKRUN DR
-----------------------------------------------------
City | COPLEY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44321-1374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-808-0661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PTA .03673
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | LMT 33. 009335
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------