=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750091971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOGAN ROSS BRAUER PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2022
-----------------------------------------------------
Last Update Date | 11/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 ALLEN RD
-----------------------------------------------------
City | STOW
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44224-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-945-3150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2869 7TH ST
-----------------------------------------------------
City | CUYAHOGA FALLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44221-2003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-202-8396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT019336
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------