1770690760 NPI number — WESTSHORE PRIMARY CARE ASSOC INC

Table of content: (NPI 1770690760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770690760 NPI number — WESTSHORE PRIMARY CARE ASSOC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTSHORE PRIMARY CARE ASSOC 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:
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:
1770690760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26908 DETROIT RD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44145-2398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-617-1823
Provider Business Mailing Address Fax Number:
440-617-0884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5343 MEADOW LANE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEFFIELD VILLAGE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44035-1469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-934-0276
Provider Business Practice Location Address Fax Number:
440-934-6947
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLAYLOCK
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
440-892-6406

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0858077 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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