Individual
EWA B BAK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1611 S GREEN RD STE 260, CLEVELAND, OH 44121-4192
(216) 297-2059
Mailing address
1611 S GREEN RD STE 260, SOUTH EUCLID, OH 44121-4192
(216) 297-2059
(216) 297-2066
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
36870
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000216081
BLUE CROSS & BLUE SHIELD
KY
01
—
022092900
BLACK LUNG INSURANCE
KY
01
—
110231108
RAILROAD MEDICARE
KY
01
—
1283881
UNITED MINE WORKERS ASSOC
KY
05
—
64046006
—
KY
01
—
7140400
AETNA INSURANCE COMPANY
KY
Enumeration date
06/20/2006
Last updated
12/16/2020
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