Provider Demographics
NPI:1467093146
Name:EVANOFF, PETER JACOB
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JACOB
Last Name:EVANOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12395 MCCRACKEN RD STE A-UP
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12395 MCCRACKEN RD STE A-UP
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2967
Practice Address - Country:US
Practice Address - Phone:216-587-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator