Provider Demographics
NPI:1518105519
Name:GERIATRIC PHYSICIAN ASSISTANTS LLC
Entity type:Organization
Organization Name:GERIATRIC PHYSICIAN ASSISTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:IRAVANI
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:440-506-3058
Mailing Address - Street 1:3843 SAVOY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1719
Mailing Address - Country:US
Mailing Address - Phone:440-506-3058
Mailing Address - Fax:
Practice Address - Street 1:842 CORPORATE WAY
Practice Address - Street 2:SUITE 850
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1537
Practice Address - Country:US
Practice Address - Phone:440-871-4700
Practice Address - Fax:440-871-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicare PIN