1790892792 NPI number — WESTSHORE PRIMARY CARE ASSOC INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790892792 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:
1790892792
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2016
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:
29325 HEALTH CAMPUS DR
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-835-6142
Provider Business Practice Location Address Fax Number:
440-899-4383
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEUN
Authorized Official First Name:
CARLA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
440-892-6406

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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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