1184670028 NPI number — COMMONWEALTH REHABILITATION AND SPORTS MEDICINE, P.S.C.

Table of content: (NPI 1184670028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184670028 NPI number — COMMONWEALTH REHABILITATION AND SPORTS MEDICINE, P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH REHABILITATION AND SPORTS MEDICINE, P.S.C.
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:
HEARTLAND SPORTS MEDICINE & REHABILITATION
Provider Other Organization Name Type Code:
3
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:
1184670028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3425 EXECUTIVE PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606-1333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-537-0764
Provider Business Mailing Address Fax Number:
419-537-0948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
193 GLADES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEREA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40403-1369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-986-1055
Provider Business Practice Location Address Fax Number:
859-986-1002
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCRAY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
419-537-0764

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 412190836-02 . This is a "OHIO BWC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 611270800 . This is a "DEPARTMENT OF LABOR/OWCP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8790053600 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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