Provider Demographics
NPI:1063414811
Name:LOFGREN, GARY (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:LOFGREN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7334
Practice Address - Fax:216-844-3781
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH211639367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0583328OtherBCMH
OHP00457955OtherRAILROAD MEDICARE
OH748693OtherBUCKEYE MEDICAID
OH000000221232OtherUNISON
OH0918761Medicaid
OH415004OtherWELLCARE MEDICAID
OH000000515994OtherANTHEM
OH7109263OtherAETNA
OHLO8215218Medicare PIN
OHP00457955OtherRAILROAD MEDICARE
OHLO8239441Medicare PIN