Provider Demographics
NPI:1679649354
Name:KAISER FOUNDATION HEALTH PLAN OF OHIO
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF OHIO
Other - Org Name:PARMA AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:FAERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-479-5136
Mailing Address - Street 1:12301 SNOW ROAD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44130
Mailing Address - Country:US
Mailing Address - Phone:216-265-8810
Mailing Address - Fax:216-265-8890
Practice Address - Street 1:12301 SNOW ROAD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44130
Practice Address - Country:US
Practice Address - Phone:216-265-8810
Practice Address - Fax:216-265-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211372Medicaid
OH9911441Medicare ID - Type Unspecified
OH3610541Medicare PIN