Provider Demographics
NPI:1043302128
Name:KYCHUN, GREGORY G (AA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:KYCHUN
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6260
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67-000069367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0583328OtherBCMH
OH000000232166OtherUNISON
OH2612891Medicaid
OHP00416770OtherRAILROAD MEDICARE
OH414995OtherWELLCARE MEDICAID
OH7867956OtherAETNA
OH000000515967OtherANTHEM
OH000000232166OtherUNISON