=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619076957
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE E. JASKIW M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 BRECKSVILLE RD PSYCHIATRY SERVICE 116A(B), LOUIS STOKES CLEVELAND VAMC
-----------------------------------------------------
City | BRECKSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44141-3204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-526-3030
-----------------------------------------------------
Fax | 440-717-2838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1772 OAKMOUNT RD
-----------------------------------------------------
City | SOUTH EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44121-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-297-0344
-----------------------------------------------------
Fax | 440-717-2838
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 35-05-9982-J
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------