Provider Demographics
NPI:1598731275
Name:BAMBAKIDIS, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BAMBAKIDIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20525 CENTER RIDGE RD
Mailing Address - Street 2:STE 220
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-333-2935
Practice Address - Street 1:25200 CENTER RIDGE RD
Practice Address - Street 2:STE 2100
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145
Practice Address - Country:US
Practice Address - Phone:440-331-4053
Practice Address - Fax:440-331-4073
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058627B2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000246863OtherANTHEM
CA4511OtherGROUP RR MEDICARE
4117752OtherAETNA
0119204OtherGROUP MEDICAID
9273172OtherGROUP MEDICARE
102920OtherKAISER
10788157OtherCAQH
F58622OtherSUMMACARE APEX
1780634279OtherGROUP NPI
341783789093OtherCARESOURCE
3610861OtherGROUP ASC MEDICARE
0501061OtherUNITED HEALTHCARE
OH0749284Medicaid
D3683041OtherGROUP IND DIAGNOSTICS MED
CA4511OtherGROUP RR MEDICARE
D3683041OtherGROUP IND DIAGNOSTICS MED
34-1783789OtherGROUP TIN