Basic Information
| Provider Information | |||||||||
| NPI: | 1588634562 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAN | ||||||||
| FirstName: | ADRIAN | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30680 BAINBRIDGE RD | ||||||||
| Address2: | NORTHEAST OHIO GROUP PRACTICE | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405425023 | ||||||||
| FaxNumber: | 4405425029 | ||||||||
| Practice Location | |||||||||
| Address1: | 29000 CENTER RIDGE RD | ||||||||
| Address2: | ST JOHN WEST SHORE HOSPITAL | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408358000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208600000X | 35085934 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2567119 | 05 | OH | MEDICAID |