Provider Demographics
NPI:1760798318
Name:GREGORY T CLASSEN DO INC
Entity Type:Organization
Organization Name:GREGORY T CLASSEN DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:330-468-4554
Mailing Address - Street 1:885 W AURORA RD STE 4
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44067-1600
Mailing Address - Country:US
Mailing Address - Phone:330-468-4554
Mailing Address - Fax:330-468-4575
Practice Address - Street 1:885 W AURORA RD STE 4
Practice Address - Street 2:
Practice Address - City:SAGAMORE HILLS
Practice Address - State:OH
Practice Address - Zip Code:44067-1600
Practice Address - Country:US
Practice Address - Phone:330-468-4554
Practice Address - Fax:330-468-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002808208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0487512Medicare UPIN