Provider Demographics
NPI:1124137476
Name:FANAROFF, AVROY A (MD)
Entity type:Individual
Prefix:
First Name:AVROY
Middle Name:A
Last Name:FANAROFF
Suffix:
Gender:M
Credentials:MD
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:216-844-7700
Practice Address - Fax:440-449-1555
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-034111208000000X, 207L00000X, 2080N0001X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000221252OtherUNISON
OH745905OtherBUCKEYE
OH000000028185OtherANTHEM
OH0182556OtherBCMH
OH0182556Medicaid
OH363519OtherWELLCARE
OH400722OtherAETNA
OH0182556Medicaid
OH745905OtherBUCKEYE
OH400722OtherAETNA