Basic Information
| Provider Information | |||||||||
| NPI: | 1598731275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAMBAKIDIS | ||||||||
| FirstName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20525 CENTER RIDGE RD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 25200 CENTER RIDGE RD | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403314053 | ||||||||
| FaxNumber: | 4403314073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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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 | 2084N0400X | 35058627B | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 000000246863 | 01 | ANTHEM | OTHER | CA4511 | 01 | GROUP RR MEDICARE | OTHER | 4117752 | 01 | AETNA | OTHER | 0119204 | 01 | GROUP MEDICAID | OTHER | 9273172 | 01 | GROUP MEDICARE | OTHER | 102920 | 01 | KAISER | OTHER | 10788157 | 01 | CAQH | OTHER | F58622 | 01 | SUMMACARE APEX | OTHER | 1780634279 | 01 | GROUP NPI | OTHER | 341783789093 | 01 | CARESOURCE | OTHER | 3610861 | 01 | GROUP ASC MEDICARE | OTHER | 0501061 | 01 | UNITED HEALTHCARE | OTHER | 0749284 | 05 | OH | MEDICAID | D3683041 | 01 | GROUP IND DIAGNOSTICS MED | OTHER |