Provider Demographics
NPI:1366628620
Name:JOSEPH G. VAN KEUREN
Entity type:Organization
Organization Name:JOSEPH G. VAN KEUREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:SZIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-365-2021
Mailing Address - Street 1:1212 ABBE RD N
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1600
Mailing Address - Country:US
Mailing Address - Phone:440-365-2021
Mailing Address - Fax:440-365-2033
Practice Address - Street 1:1212 ABBE RD N
Practice Address - Street 2:SUITE B
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1600
Practice Address - Country:US
Practice Address - Phone:440-365-2021
Practice Address - Fax:440-365-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0494870001Medicare NSC