Basic Information
| Provider Information | |||||||||
| NPI: | 1154395820 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST VINCENT CHARITY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST VINCENT CHARITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6935 TREELINE DR | ||||||||
| Address2: | SUITE J | ||||||||
| 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: | 02/17/2006 | ||||||||
| LastUpdateDate: | 05/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCMAHON | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2168754602 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. VINCENT CHARITY MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 341893452002 | 01 | CHAMPUS | OTHER | 341893452006 | 01 | OH | MEDICAL MUTUAL OF OHIO | OTHER |