1194943860 NPI number — GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO

Table of content: (NPI 1194943860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194943860 NPI number — GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO
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:
1194943860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 NINTH STREET SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-445-1059
Provider Business Mailing Address Fax Number:
330-454-1014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 NINTH STREET SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44707-4714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-445-1035
Provider Business Practice Location Address Fax Number:
330-454-1014
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TREW
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
330-445-1035

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  A00436 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SP2281 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SP8183 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SP3189 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 733018 . This is a "BUCKEYE-MEDICAID HMO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 733018 . This is a "BUCKEYE HEALTH PLAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0303042 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3303884 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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