Provider Demographics
NPI:1104082031
Name:WESTERN RESERVE VASCULAR INSTITUTE
Entity type:Organization
Organization Name:WESTERN RESERVE VASCULAR INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:G
Authorized Official - Last Name:PROTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-953-3515
Mailing Address - Street 1:813 KENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5004
Mailing Address - Country:US
Mailing Address - Phone:330-953-3515
Mailing Address - Fax:330-953-0313
Practice Address - Street 1:813 KENTWOOD DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5004
Practice Address - Country:US
Practice Address - Phone:330-953-3515
Practice Address - Fax:330-953-0313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-0084462086S0129X
OH2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2688846Medicaid
OH2688846Medicaid
OH9377741Medicare PIN