1073938122 NPI number — FAIRFAX PLACE AT HOME NM, LLC

Table of content: MR. MARK NEAL GORMAN CRNA (NPI 1831192343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073938122 NPI number — FAIRFAX PLACE AT HOME NM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX PLACE AT HOME NM, LLC
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:
1073938122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9014 CEDAR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44106-2932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-795-1363
Provider Business Mailing Address Fax Number:
216-795-8060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9014 CEDAR AVE
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:
44106-2932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-795-1363
Provider Business Practice Location Address Fax Number:
216-795-8060
Provider Enumeration Date:
02/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
HERMAN
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
216-795-1363

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , 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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