Basic Information
| Provider Information | |||||||||
| NPI: | 1023359023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTSHORE PRIMARY CARE ASSOC., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26908 DETROIT RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406171823 | ||||||||
| FaxNumber: | 4406170884 | ||||||||
| Practice Location | |||||||||
| Address1: | 20455 LORAIN RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FAIRVIEW PARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441263494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403535477 | ||||||||
| FaxNumber: | 4403565885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2013 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | BLAYLOCK | ||||||||
| AuthorizedOfficialFirstName: | MISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4408926406 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0858077 | 05 | OH | MEDICAID |