Provider Demographics
NPI:1538126693
Name:WESTERN RESERVE PROFESSIONAL GROUP INC
Entity Type:Organization
Organization Name:WESTERN RESERVE PROFESSIONAL GROUP INC
Other - Org Name:OCC MED SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SEMANCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-548-0080
Mailing Address - Street 1:PO BOX 951971
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0021
Mailing Address - Country:US
Mailing Address - Phone:330-548-0080
Mailing Address - Fax:330-548-0085
Practice Address - Street 1:174 CURRIE HALL PKWY
Practice Address - Street 2:STE D
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4387
Practice Address - Country:US
Practice Address - Phone:330-548-0086
Practice Address - Fax:330-548-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0670573Medicaid
OHMO0705996Medicare ID - Type UnspecifiedMEDICARE PROVIDER