Basic Information
| Provider Information | |||||||||
| NPI: | 1205990595 | ||||||||
| 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: | 1611 S GREEN RD | ||||||||
| Address2: | SUITE 237 | ||||||||
| City: | SOUTH EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441214128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168441000 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 12/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2169833175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 2691903 | 05 | OH | MEDICAID |