1578707659 NPI number — ST CYRIL PAIN CLINIC

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 1578707659 NPI number — ST CYRIL PAIN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST CYRIL PAIN CLINIC
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:
1578707659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 SAHARA TRL
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44514-3691
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-729-0111
Provider Business Mailing Address Fax Number:
330-729-1333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 ELM RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORTLAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44410-9393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-729-0111
Provider Business Practice Location Address Fax Number:
330-729-1333
Provider Enumeration Date:
04/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ANDREWS
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
NAGUIB
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
216-509-0842

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  35090324 , 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: 000000612329 . This is a "ANTHEM BLUE CROSS/BLUE SHIELD OF OHIO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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