=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184333007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY CONNACHER SPT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2022
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11100 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44106-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-844-2724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2615 DETROIT AVE APT 518
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44113-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-289-5491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT005680
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------