1013395367 NPI number — BERTA LEISY STROUD MD

Table of content: BERTA LEISY STROUD MD (NPI 1013395367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013395367 NPI number — BERTA LEISY STROUD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STROUD
Provider First Name:
BERTA
Provider Middle Name:
LEISY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CERRO GOMEZ
Provider Other First Name:
BERTA
Provider Other Middle Name:
LEISY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013395367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1332
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47402-1332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-345-8188
Provider Business Mailing Address Fax Number:
844-338-4526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9500 EUCLID AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44195-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-444-0660
Provider Business Practice Location Address Fax Number:
216-444-7360
Provider Enumeration Date:
05/07/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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