Basic Information
| Provider Information | |||||||||
| NPI: | 1134201825 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EMANCIPATOR | ||||||||
| FirstName: | STEVEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CTR RD | ||||||||
| Address2: | MSC 9152 | ||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 06/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZI0100X | 34047991 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Immunopathology | 207ZP0101X | 35047991 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0105X | 35047991 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 363507 | 01 | OH | WELLCARE | OTHER | 000000528747 | 01 | OH | ANTHEM | OTHER | 0498546 | 05 | OH | MEDICAID | 750544 | 01 | OH | BUCKEYE | OTHER | 0639660 | 01 | OH | AETNA | OTHER | 341794737008 | 01 | OH | MMO | OTHER | 000000030170 | 01 | OH | ANTHEM | OTHER | 000000224364 | 01 | OH | UNISON | OTHER | 639660 | 01 | OH | AETNA | OTHER |