1750386629 NPI number — DR. PAUL H EISENBERG DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750386629 NPI number — DR. PAUL H EISENBERG DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EISENBERG
Provider First Name:
PAUL
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EISENBERG
Provider Other First Name:
PAUL
Provider Other Middle Name:
H
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM, INC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750386629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9485 MENTOR AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
MENTOR
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44060-8723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-205-5878
Provider Business Mailing Address Fax Number:
440-375-8830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9485 MENTOR AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
MENTOR
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44060-8723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-205-5878
Provider Business Practice Location Address Fax Number:
440-375-8830
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  001670 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0245363 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480031301 . This is a "RAILROAD MEDICARE LAKEWOO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 480014163 . This is a "RAILROAD MEDICARE BEREA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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