Provider Demographics
NPI:1659445773
Name:NORTHEAST OHIO MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTHEAST OHIO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUNYEWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-761-9617
Mailing Address - Street 1:13944 EUCLID AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-3832
Mailing Address - Country:US
Mailing Address - Phone:216-761-9617
Mailing Address - Fax:
Practice Address - Street 1:13944 EUCLID AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-3832
Practice Address - Country:US
Practice Address - Phone:216-761-9617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
OHPENDINGMedicaid