1497806970 NPI number — SUBURBAN FAMILY SERVICES

Table of content: GUY RUDOLPH MOISE DO (NPI 1366431983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497806970 NPI number — SUBURBAN FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN FAMILY SERVICES
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:
1497806970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23360 CHAGRIN BLVD
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-5547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-591-0322
Provider Business Mailing Address Fax Number:
216-360-7376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23360 CHAGRIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
BEACHWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44122-5547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-591-0322
Provider Business Practice Location Address Fax Number:
216-360-7376
Provider Enumeration Date:
01/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IANNONE
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
216-591-0322

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000165856 . This is a "ANTHEM BLUE CROSS & BLUE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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