Provider Demographics
NPI:1407849375
Name:BREWER, THEODORE K (AA-C)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:K
Last Name:BREWER
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19250 BAGLEY RD
Mailing Address - Street 2:#101
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3314
Mailing Address - Country:US
Mailing Address - Phone:440-891-8800
Mailing Address - Fax:440-891-1734
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-827-5000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67-000032367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000334911OtherANTHEM BCBS
OH2253243Medicaid
OH2253243Medicaid