Basic Information
| Provider Information | |||||||||
| NPI: | 1013954395 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY UROLOGISTS OF CLEVELAND INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5910 LANDERBROOK DR | ||||||||
| Address2: | #250 | ||||||||
| City: | MAYFIELD HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441246508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406845865 | ||||||||
| FaxNumber: | 4404491555 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168441900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FLANAGAN | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2168441900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 103T00000X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | CB0092 | 01 | OH | RAILROAD MEDICARE | OTHER | 0857256 | 05 | OH | MEDICAID |