MEDICARE: GEAUGA SPORTS MEDICINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083S0010X	Sports Medicine (Preventive Medicine) Physician		OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	250006704	OTHER	OH	RR MEDICARE

General Provider Information

NPI Number	:	1396746970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEAUGA SPORTS MEDICINE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 567
Second Line	:
City	:	CHAGRIN FALLS
State	:	OH
Zip	:	44022-0567
Country	:	US
Telephone Number	:	216-464-5160
Fax Number	:	216-464-5982

Provider Business Practice Location Address
First Line	:	13207 RAVENNA RD
Second Line	:
City	:	CHARDON
State	:	OH
Zip	:	44024-7032
Country	:	US
Telephone Number	:	440-285-6452
Fax Number	:	440-285-1796

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL J KELIS
Credential	:	D.O.
Telephone Number	:	440-285-6452

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/21/2022

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