Provider Demographics
NPI:1134200132
Name:JACK RZEPKA, M.D., INC.
Entity type:Organization
Organization Name:JACK RZEPKA, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:RZEPKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-752-9055
Mailing Address - Street 1:4200 WARRENSVILLE CENTER RD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7051
Mailing Address - Country:US
Mailing Address - Phone:216-752-9055
Mailing Address - Fax:216-752-0990
Practice Address - Street 1:4200 WARRENSVILLE CENTER RD
Practice Address - Street 2:SUITE 420
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7051
Practice Address - Country:US
Practice Address - Phone:216-752-9055
Practice Address - Fax:216-752-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-051524R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2714281Medicaid
OH2714281Medicaid
OHDF5972Medicare PIN