Basic Information
| Provider Information | |||||||||
| NPI: | 1003860487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND CLINIC HEALTH SYSTEM - EAST REGION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EUCLID HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 BRECKSVILLE RD | ||||||||
| Address2: | SUITE 20 RK 10 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441315032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166368052 | ||||||||
| FaxNumber: | 2166368088 | ||||||||
| Practice Location | |||||||||
| Address1: | 18901 LAKE SHORE BLVD | ||||||||
| Address2: | |||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441191078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165319000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONGVILLE | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCT OFFICER AND CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2166367146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 1133 | OH | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 5000053 | 01 | UNITED HEALTHCARE | OTHER | 2593420 | 05 | OH | MEDICAID | 000000157022 | 01 | OH | ANTHEM | OTHER | 100118 | 01 | OH | KAISER | OTHER | 0059416 | 01 | OH | AETNA | OTHER | 340714616-00 | 01 | OH | BUREAU WORKERS COMPENSATI | OTHER |