Provider Demographics
NPI:1962118547
Name:HILLER, JERALD MARK
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:MARK
Last Name:HILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18867 N VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1759
Mailing Address - Country:US
Mailing Address - Phone:440-333-3513
Mailing Address - Fax:
Practice Address - Street 1:18867 N VALLEY DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-1759
Practice Address - Country:US
Practice Address - Phone:440-333-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRM331362172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH103793839499Medicaid