Basic Information
| Provider Information | |||||||||
| NPI: | 1972905867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBGYN OF WESTLAKE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30701 LORAIN RD STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440706325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 CROCKER RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441457603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408712222 | ||||||||
| FaxNumber: | 4402494111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | BACHUWA | ||||||||
| AuthorizedOfficialFirstName: | RIMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4408712222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2313468 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2313468 | 01 | OH | BUSINESS LICENSE | OTHER |