Provider Demographics
NPI:1932386919
Name:RIDGEPARK FAMILY PRACTICE
Entity Type:Organization
Organization Name:RIDGEPARK FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KUSHNAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:216-398-5535
Mailing Address - Street 1:5500 RIDGE ROAD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129
Mailing Address - Country:US
Mailing Address - Phone:216-398-5535
Mailing Address - Fax:440-882-3304
Practice Address - Street 1:5500 RIDGE ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-2367
Practice Address - Country:US
Practice Address - Phone:216-398-5535
Practice Address - Fax:440-882-3304
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIDGEPARK FAMILY PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-22
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2651938Medicaid
OH2651938Medicaid