1558392100 NPI number — EAGLE CREEK HEALTHCARE GROUP, INC.

Table of content: (NPI 1558392100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558392100 NPI number — EAGLE CREEK HEALTHCARE GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE CREEK HEALTHCARE GROUP, INC.
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:
1558392100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23700 COMMERCE PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-5827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-292-5706
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 SPRUCE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST UNION
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45693-8807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-544-5531
Provider Business Practice Location Address Fax Number:
937-544-3478
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEISBERG
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
I.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
216-292-5706

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1758N , 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)

  • Identifier: 2700116 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com