Provider Demographics
NPI:1467553206
Name:CENTER FOR VASCULAR AND THORACIC MEDICINE AND SURGERY, INC
Entity Type:Organization
Organization Name:CENTER FOR VASCULAR AND THORACIC MEDICINE AND SURGERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEKOTA
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:440-233-1003
Mailing Address - Street 1:2173 N RIDGE RD E
Mailing Address - Street 2:SUITE A
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3400
Mailing Address - Country:US
Mailing Address - Phone:440-277-5077
Mailing Address - Fax:440-277-6696
Practice Address - Street 1:2173 N RIDGE RD E
Practice Address - Street 2:SUITE A
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3400
Practice Address - Country:US
Practice Address - Phone:440-277-5077
Practice Address - Fax:440-277-6696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053879208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0636306Medicaid
OH0636306Medicaid