1134201825 NPI number — STEVEN EMANCIPATOR

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134201825 NPI number — STEVEN EMANCIPATOR

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

EMANCIPATOR

Provider First Name:

STEVEN

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

M

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:

1134201825

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/05/2008

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3605 WARRENSVILLE CTR RD

Provider Second Line Business Mailing Address:

MSC 9152

Provider Business Mailing Address City Name:

SHAKER HTS

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

44122

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

216-286-6299

Provider Business Mailing Address Fax Number:

216-286-6341

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:

216-844-7494

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

10/20/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207ZI0100X , with the licence number:  34047991 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0101X , with the licence number: 35047991 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0105X , with the licence number: 35047991 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 363507 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000528747 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 0498546 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 750544 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 0639660 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 341794737008 . This is a "MMO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000030170 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000224364 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 639660 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".