Provider Demographics
NPI:1912094145
Name:WESTERN RESERVE PROFESSIONAL GROUP
Entity Type:Organization
Organization Name:WESTERN RESERVE PROFESSIONAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEMANCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-677-3628
Mailing Address - Street 1:307 W MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-2400
Mailing Address - Country:US
Mailing Address - Phone:330-677-3628
Mailing Address - Fax:330-677-3626
Practice Address - Street 1:6847 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-677-3628
Practice Address - Fax:330-677-3626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWE9283485Medicare ID - Type Unspecified