Provider Demographics
NPI:1073713939
Name:OBSTETRICAL & GYNECOLOGICAL
Entity Type:Organization
Organization Name:OBSTETRICAL & GYNECOLOGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:DUANGJAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-286-6633
Mailing Address - Street 1:12475 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9028
Mailing Address - Country:US
Mailing Address - Phone:440-286-6633
Mailing Address - Fax:
Practice Address - Street 1:12475 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9028
Practice Address - Country:US
Practice Address - Phone:440-286-6633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034212207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0206744Medicaid
OH0206744Medicaid
OHOB9264681Medicare PIN