1568536639 NPI number — MR. RUSSELL J WEINMAN PT

Table of content: MR. RUSSELL J WEINMAN PT (NPI 1568536639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568536639 NPI number — MR. RUSSELL J WEINMAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEINMAN
Provider First Name:
RUSSELL
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1568536639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3866 CARNEGIE 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:
44115-2718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-621-0022
Provider Business Mailing Address Fax Number:
216-621-5479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3866 CARNEGIE 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:
44115-2718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-621-0022
Provider Business Practice Location Address Fax Number:
216-621-5479
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT001848 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: AT000175 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0773462 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2101504 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34-13971587A12 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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