Basic Information
| Provider Information | |||||||||
| NPI: | 1144452509 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HOSPITALS MEDICAL GROUP | ||||||||
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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: | 5778 DARROW RD | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442363808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168443601 | ||||||||
| FaxNumber: | 2168447117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2009 | ||||||||
| LastUpdateDate: | 06/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2167678717 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 2691903 | 05 | OH | MEDICAID | 5972910008 | 01 | OH | DMERC | OTHER |