Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 35.142728 | OH |
Y | 213ES0000X | Sports Medicine | 35.142728 | OH |
NPI | 1487001566 |
---|---|
Provider Name | Matthew George Mitchkash |
First Address | Cleveland, OH 44195-0001 |
Second Address | Cleveland, OH 44195-3109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2016 |
Last Update Date | 12/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
270535 | CERTIFICATE OF LIMITED REGISTRATION (01) | MA |