1578880431 NPI number — CLEVELAND COMMUNITY PHYSICIANS INC

Table of content: (NPI 1578880431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578880431 NPI number — CLEVELAND COMMUNITY PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEVELAND COMMUNITY PHYSICIANS INC
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:
1578880431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 771103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44107-0047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-472-2730
Provider Business Mailing Address Fax Number:
216-472-2740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
398 W BAGLEY RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BEREA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44017-1369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-816-1120
Provider Business Practice Location Address Fax Number:
440-816-1022
Provider Enumeration Date:
04/30/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCLONEY
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
440-816-1120

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3088699 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".