Basic Information
| Provider Information | |||||||||
| NPI: | 1407845902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REISMAN | ||||||||
| FirstName: | JON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26908 DETROIT RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406171823 | ||||||||
| FaxNumber: | 4406170884 | ||||||||
| Practice Location | |||||||||
| Address1: | 2322 E 22ND ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163633309 | ||||||||
| FaxNumber: | 2163632768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 35048202 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0511628 | 05 | OH | MEDICAID | 900003186 | 01 | OH | RR MEDICARE | OTHER |