MEDICARE: KO NURSE PRACTITIONER, 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	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1912287624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KO NURSE PRACTITIONER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 74692
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44194-0775
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15800 DETROIT AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-3748
Country	:	US
Telephone Number	:	216-226-8700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GEORGE KHURI
Credential	:	MD
Telephone Number	:	216-521-2255

Provider Enumeration Date	:	08/25/2011
Last Update Date	:	09/20/2016

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