=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144281288
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT MARK ZNIDARSIC MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2006
-----------------------------------------------------
Last Update Date | 03/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 FIFTH AVE
-----------------------------------------------------
City | CHARDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-279-1500
-----------------------------------------------------
Fax | 440-279-1501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7590 AUBURN ROAD, SUITE 014 ATTN: MED STAFF
-----------------------------------------------------
City | WILLOUGHBY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-9176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-354-1899
-----------------------------------------------------
Fax | 440-354-1845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35-071035
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------