1639152457 NPI number — MATTHEW A PASSALACQUA DO

Table of content: MATTHEW A PASSALACQUA DO (NPI 1639152457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639152457 NPI number — MATTHEW A PASSALACQUA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PASSALACQUA
Provider First Name:
MATTHEW
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1639152457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24701 EUCLID AVE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44117-1714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11100 EUCLID AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-844-1700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2005

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: 2085R0204X , with the licence number:  34005244P , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085D0003X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085H0002X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0203X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207U00000X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0903X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0902X , with the licence number: 34005244 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00454367 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 421816 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0924398 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00224514 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 733909 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000550367 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000364066 . This is a "ANTHEM ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0304914 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5261551 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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