Provider Demographics
NPI:1427041714
Name:MENENDEZ, GREGORY (AA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MENENDEZ
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0567
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:29017 CEDAR RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4073
Practice Address - Country:US
Practice Address - Phone:440-460-8000
Practice Address - Fax:440-460-1759
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67000018367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1427041714Medicaid
OH000000515970OtherANTHEM
OH415010OtherWELLCARE MEDICAID
OH0583328OtherBCMH
OH2491021Medicaid
OH7405896OtherAETNA
OHP00405856OtherMEDICARE RAILROAD
OH000000232169OtherUNISON
OHME4120402Medicare PIN
OHME4120406Medicare PIN