Provider Demographics
NPI:1447529656
Name:NORTH EASTERN OHIO PODIATRY GROUP LLC
Entity type:Organization
Organization Name:NORTH EASTERN OHIO PODIATRY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GLUKH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-953-3668
Mailing Address - Street 1:35010 CHARDON RD
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9011
Mailing Address - Country:US
Mailing Address - Phone:440-953-3668
Mailing Address - Fax:440-953-3556
Practice Address - Street 1:35010 CHARDON RD
Practice Address - Street 2:SUITE 101A
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9011
Practice Address - Country:US
Practice Address - Phone:440-953-3668
Practice Address - Fax:440-953-3556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H074350Medicare PIN