1417933755 NPI number — TERENCE LEIGH WITHAM MD

Table of content: TERENCE LEIGH WITHAM MD (NPI 1417933755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417933755 NPI number — TERENCE LEIGH WITHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITHAM
Provider First Name:
TERENCE
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1417933755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7575 NORTHCLIFF AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44144-3267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-661-4577
Provider Business Mailing Address Fax Number:
216-661-4784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7575 NORTHCLIFF AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44144-3267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-661-4577
Provider Business Practice Location Address Fax Number:
216-661-4784
Provider Enumeration Date:
12/19/2005

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: 2084P0800X , with the licence number:  35-081587 , 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: 0256582 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2350147 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000241215 . This is a "ANTHEM PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 260051953 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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