=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124077540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAILAJA SUNDARESH M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 11/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26250 EUCLID AVE SUITE 203
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44132-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-261-2333
-----------------------------------------------------
Fax | 216-289-0748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275 SPRINGSIDE DR STE 100
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-4549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 35-039142
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------