Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | PT05915 | OH |
NPI | 1114931292 |
---|---|
Provider Name | Edward Anthony Jendrisak |
First Address | Richfield, OH 44286-9576 |
Second Address | Richfield, OH 44286-9576 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 08/07/2007 |