MEDICARE: NORTH EASTERN OHIO PODIATRY GROUP 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	213ES0103X	Foot & Ankle Surgery Podiatrist		OH

General Provider Information

NPI Number	:	1447529656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH EASTERN OHIO PODIATRY GROUP LLC

Provider Business Mailing Address
First Line	:	35010 CHARDON RD
Second Line	:	SUITE 101A
City	:	WILLOUGHBY HILLS
State	:	OH
Zip	:	44094-9011
Country	:	US
Telephone Number	:	440-953-3668
Fax Number	:	440-953-3556

Provider Business Practice Location Address
First Line	:	35010 CHARDON RD
Second Line	:	SUITE 101A
City	:	WILLOUGHBY HILLS
State	:	OH
Zip	:	44094-9011
Country	:	US
Telephone Number	:	440-953-3668
Fax Number	:	440-953-3556

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. VADIM GLUKH
Credential	:	DPM
Telephone Number	:	440-953-3668

Provider Enumeration Date	:	12/16/2011
Last Update Date	:	07/24/2012

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