Provider Demographics
NPI:1104994078
Name:CIAVARELLA, ANTHONY J (PA-C)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:CIAVARELLA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23250 MERCANTILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5928
Mailing Address - Country:US
Mailing Address - Phone:216-831-7855
Mailing Address - Fax:216-831-5320
Practice Address - Street 1:23250 MERCANTILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5928
Practice Address - Country:US
Practice Address - Phone:216-831-7855
Practice Address - Fax:216-831-5320
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCIPA13131Medicare ID - Type Unspecified