Provider Demographics
NPI:1669687760
Name:WALTER J PASSARELLO, DO LLC
Entity Type:Organization
Organization Name:WALTER J PASSARELLO, DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PASSARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-757-7888
Mailing Address - Street 1:3584 TIMBERBROOKE TRL
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-5321
Mailing Address - Country:US
Mailing Address - Phone:330-757-7888
Mailing Address - Fax:330-757-4912
Practice Address - Street 1:8064 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6153
Practice Address - Country:US
Practice Address - Phone:330-757-7888
Practice Address - Fax:330-757-4912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006450208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2101120Medicaid
OH2101120Medicaid
OHG83896Medicare UPIN