Provider Demographics
NPI:1891819140
Name:PREM S. JAWA, MD., INC
Entity Type:Organization
Organization Name:PREM S. JAWA, MD., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-SELF
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:S
Authorized Official - Last Name:JAWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-286-5464
Mailing Address - Street 1:13170 RAVENA RD.
Mailing Address - Street 2:STE #100
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-7025
Mailing Address - Country:US
Mailing Address - Phone:440-286-5464
Mailing Address - Fax:440-286-8386
Practice Address - Street 1:13170 RAVENNA RD
Practice Address - Street 2:STE 100
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7025
Practice Address - Country:US
Practice Address - Phone:440-286-5464
Practice Address - Fax:440-286-8386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2832368Medicaid
OH2832368Medicaid