Provider Demographics
NPI:1356308407
Name:WESTERN RESERVE PROFESS
Entity Type:Organization
Organization Name:WESTERN RESERVE PROFESS
Other - Org Name:WESTERN RESERVE SPINE & PAIN INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SEMANCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-677-3628
Mailing Address - Street 1:PO BOX 951971
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0021
Mailing Address - Country:US
Mailing Address - Phone:330-548-0080
Mailing Address - Fax:330-548-0084
Practice Address - Street 1:307 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2400
Practice Address - Country:US
Practice Address - Phone:330-677-3628
Practice Address - Fax:330-677-3626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2311331Medicaid
OH2374434Medicaid
OH0251070Medicaid
OH2082866Medicaid
OHU30664Medicare UPIN
OHG83617Medicare UPIN
OH2311331Medicaid
OH2374434Medicaid
OH4148851Medicare PIN
OH4066821Medicare PIN
OH12991Medicare PIN
OHP88268Medicare UPIN
OH4069412Medicare UPIN
OHMO0705996Medicare ID - Type UnspecifiedMEDICARE PROVIDER
OH4085673Medicare PIN
OH9283485Medicare PIN
OH4133101Medicare PIN
OH4086482Medicare PIN
OH4180451Medicare PIN