1972591121 NPI number — GLENN JOSEPH MEDEN MD

Table of content: GLENN JOSEPH MEDEN MD (NPI 1972591121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972591121 NPI number — GLENN JOSEPH MEDEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDEN
Provider First Name:
GLENN
Provider Middle Name:
JOSEPH
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:
1972591121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 SOM CENTER RD
Provider Second Line Business Mailing Address:
#25
Provider Business Mailing Address City Name:
MAYFIELD HTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44124-2118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-446-1423
Provider Business Mailing Address Fax Number:
440-446-1498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6770 MAYFIELD RD
Provider Second Line Business Practice Location Address:
#305
Provider Business Practice Location Address City Name:
MAYFIELD HTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44124-2299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-442-2554
Provider Business Practice Location Address Fax Number:
440-442-3709
Provider Enumeration Date:
10/12/2005

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: 207RC0200X , with the licence number:  35046953 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 35046953 , 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: 0554083 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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