Provider Demographics
NPI:1710239991
Name:GREGORY SASARAK INC
Entity Type:Organization
Organization Name:GREGORY SASARAK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SASARAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-365-9311
Mailing Address - Street 1:280 S LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6224
Mailing Address - Country:US
Mailing Address - Phone:440-365-9311
Mailing Address - Fax:440-366-5057
Practice Address - Street 1:280 S LOGAN ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6224
Practice Address - Country:US
Practice Address - Phone:440-365-9311
Practice Address - Fax:440-366-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5592261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2642840Medicaid
OH2642840Medicaid
OHSA4173811Medicare PIN