1770117137 NPI number — ANDREA R OSBORN

Table of content: ANDREA R OSBORN (NPI 1770117137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770117137 NPI number — ANDREA R OSBORN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSBORN
Provider First Name:
ANDREA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1770117137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10863
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:
44110-0863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-224-6246
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19600 PASNOW 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:
44119-1475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-224-6246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2020

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: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1804104 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1831384 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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