Basic Information
| Provider Information | |||||||||
| NPI: | 1073827879 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSTIY HOSPTIALS MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27101 CHARDON ROAD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | RICHMOND HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168446000 | ||||||||
| FaxNumber: | 2168445727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2010 | ||||||||
| LastUpdateDate: | 08/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2163836756 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 2691903 | 05 | OH | MEDICAID |