Provider Demographics
NPI:1114197340
Name:CHAGRIN VALLEY PSYCHIATRIC ASSOCIATES INC
Entity Type:Organization
Organization Name:CHAGRIN VALLEY PSYCHIATRIC ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-227-3691
Mailing Address - Street 1:7500 THATCHUM LN
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6814
Mailing Address - Country:US
Mailing Address - Phone:440-227-3691
Mailing Address - Fax:863-438-6126
Practice Address - Street 1:7500 THATCHUM LN
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6814
Practice Address - Country:US
Practice Address - Phone:440-227-3691
Practice Address - Fax:863-438-6126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340040912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCH92497315OtherMEDICARE GROUP PIN