Provider Demographics
NPI:1376911495
Name:GEAUGA MEDICAL THERAPY CENTER LLC
Entity Type:Organization
Organization Name:GEAUGA MEDICAL THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ZAID
Authorized Official - Middle Name:
Authorized Official - Last Name:FADUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-360-4673
Mailing Address - Street 1:125 W MCDOWELL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1223
Mailing Address - Country:US
Mailing Address - Phone:855-360-4673
Mailing Address - Fax:
Practice Address - Street 1:13170 RAVENNA RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7025
Practice Address - Country:US
Practice Address - Phone:440-409-7055
Practice Address - Fax:440-279-4009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FADUL HEALTH PARTNERS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-05
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QA0401X, 261QC1500X
OH35.122879261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty