1992963680 NPI number — CLINIC MEDICAL SERVICES COMPANY

Table of content: (NPI 1992963680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992963680 NPI number — CLINIC MEDICAL SERVICES COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINIC MEDICAL SERVICES COMPANY
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:
6
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:
1992963680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6100 W CREEK RD
Provider Second Line Business Mailing Address:
SUITE 35
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44131-2133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-642-8165
Provider Business Mailing Address Fax Number:
216-642-1064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
652 YOUNGSTOWN WARREN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44446-4356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-505-2280
Provider Business Practice Location Address Fax Number:
330-505-2286
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MAIORANA
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
MANAGED CARE MANAGER
Authorized Official Telephone Number:
216-642-8165

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  1229IC , 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)





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