1093816209 NPI number — BEECH BROOK

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 1093816209 NPI number — BEECH BROOK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEECH BROOK
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:
1093816209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3737 LANDER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEPPER PIKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44124-5712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-831-2255
Provider Business Mailing Address Fax Number:
216-831-0436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3737 LANDER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEPPER PIKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-831-2255
Provider Business Practice Location Address Fax Number:
216-831-0436
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REX
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
216-831-2255

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  12773 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: 208 , 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: 0268768 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12773 . This is a "ODADAS PROVIDER CERTIFICATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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