Basic Information
| Provider Information | |||||||||
| NPI: | 1063575462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH EAST OHIO GROUP PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30575 BAINBRIDGE RD STE 200 | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441392275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405425000 | ||||||||
| FaxNumber: | 4405425005 | ||||||||
| Practice Location | |||||||||
| Address1: | 29000 CENTER RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408358000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | KLOSTERMAN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3309267974 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2267096 | 05 | OH | MEDICAID |