1063637114 NPI number — ELIZABETH M CONFALONE

Table of content: (NPI 1063637114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063637114 NPI number — ELIZABETH M CONFALONE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELIZABETH M CONFALONE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063637114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4758 RIDGE RD
Provider Second Line Business Mailing Address:
#161
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44144-3327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-236-8484
Provider Business Mailing Address Fax Number:
440-236-8470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29101 HEALTH CAMPUS DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-5270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-892-6555
Provider Business Practice Location Address Fax Number:
440-835-1996
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONFALONE
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
440-892-6555

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  36003007-C , 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: 0764856 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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