Basic Information
| Provider Information | |||||||||
| NPI: | 1083637912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST VINCENT CHARITY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST VINCENT CHARITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6935 TREELINE DR STE J | ||||||||
| Address2: | |||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441413393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407463401 | ||||||||
| FaxNumber: | 4407463405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2351 E 22ND ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168616200 | ||||||||
| FaxNumber: | 4407463405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/17/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/16/2008 | ||||||||
| NPIReactivationDate: | 08/17/2012 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSNACZYK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP SCHS/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2164364653 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
ID Information
| ID | Type | State | Issuer | Description | 0818 | 01 | OH | MACSIS | OTHER |