Provider Demographics
NPI:1831308576
Name:SHIVAPOUR, JILL KATHRYN LYON (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:KATHRYN LYON
Last Name:SHIVAPOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:KATHRYN
Other - Last Name:LYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA240046208000000X
OH35-1218692080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0088060Medicaid
OHH229650Medicare PIN