Provider Demographics
NPI:1699986620
Name:WESTERN RESERVE PROFESSIONAL GROUP INC
Entity type:Organization
Organization Name:WESTERN RESERVE PROFESSIONAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-677-3628
Mailing Address - Street 1:PO BOX 715479
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-5479
Mailing Address - Country:US
Mailing Address - Phone:330-677-3628
Mailing Address - Fax:330-677-4931
Practice Address - Street 1:307 WEST MAIN STREET
Practice Address - Street 2:SUITE C
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2400
Practice Address - Country:US
Practice Address - Phone:330-677-3628
Practice Address - Fax:330-677-4931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0251070Medicaid
OH2406275Medicaid
OH2675921Medicaid
OH0926887Medicaid
OH2082866Medicaid
OH4085673Medicaid
OH2311331Medicaid
OH2493038Medicaid
OH9283485Medicare PIN
OH2553151Medicare PIN
OH4133101Medicare PIN
OH4169412Medicare PIN
OH2493038Medicaid
OH2082866Medicaid
OH4720180001Medicare NSC
OH4066829Medicare PIN
OH4085673Medicare PIN
OH12991Medicare PIN