Provider Demographics
NPI:1134684053
Name:DR GHANEM & ASSOCIATES LLC
Entity Type:Organization
Organization Name:DR GHANEM & ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BILAL
Authorized Official - Middle Name:TAHER
Authorized Official - Last Name:GHANEM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-212-4526
Mailing Address - Street 1:3751 ALESIA KAE DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-5012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18054 ROYALTON RD
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-5180
Practice Address - Country:US
Practice Address - Phone:440-268-0765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0327710Medicaid