Basic Information
| Provider Information | |||||||||
| NPI: | 1194777227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND CLINIC HEALTH SYSTEM - EAST REGION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH POINTE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 BRECKSVILLE RD | ||||||||
| Address2: | SUITE 20 RK10 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441315032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166368052 | ||||||||
| FaxNumber: | 2166368088 | ||||||||
| Practice Location | |||||||||
| Address1: | 20000 HARVARD AVE | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441226805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164916000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | GLASS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2164449361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 1297 | OH | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 340811464-00 | 01 | OH | BUREAU WORKERS COMPENSATI | OTHER | 000000157027 | 01 | OH | ANTHEM | OTHER | 0062834 | 01 | OH | AETNA | OTHER | 5000056 | 01 | OH | UNITED HEALTHCARE | OTHER | 100120 | 01 | OH | KAISER | OTHER | 8552507 | 05 | OH | MEDICAID |