Provider Demographics
NPI:1902822653
Name:GOLLADAY, RUTH E (PA-C)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:E
Last Name:GOLLADAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:RUTH
Other - Middle Name:E
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 74253
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:440-879-0081
Mailing Address - Fax:440-879-0084
Practice Address - Street 1:18901 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1078
Practice Address - Country:US
Practice Address - Phone:216-531-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ54217Medicare UPIN
OHGOPA78761Medicare ID - Type Unspecified