1760654941 NPI number — MAUREEN A WALLACE-KING NP

Table of content: MAUREEN A WALLACE-KING NP (NPI 1760654941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760654941 NPI number — MAUREEN A WALLACE-KING NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE-KING
Provider First Name:
MAUREEN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KING
Provider Other First Name:
MAUREEN
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760654941
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1380 KINGSWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44145-2611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-525-6500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9500 EUCLID 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:
44195-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-636-1619
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2008

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: 363L00000X , with the licence number:  RN178999 , 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: 000000234659 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2806422 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000558051 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9985125 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".