Provider Demographics
NPI:1952685851
Name:OHIO PERMANENTE MEDICAL GROUP
Entity Type:Organization
Organization Name:OHIO PERMANENTE MEDICAL GROUP
Other - Org Name:KAISER PERMANENTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:FAERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-265-8844
Mailing Address - Street 1:12301 SNOW RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44130-1002
Mailing Address - Country:US
Mailing Address - Phone:216-265-8844
Mailing Address - Fax:216-265-8894
Practice Address - Street 1:7695 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5540
Practice Address - Country:US
Practice Address - Phone:216-265-8844
Practice Address - Fax:216-265-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211372Medicaid
OH9911441Medicare PIN