Basic Information
| Provider Information | |||||||||
| NPI: | 1235183542 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND CLINIC HEALTH SYSTEM - EAST REGION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH POINTE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 BRECKSVILLE RD | ||||||||
| Address2: | SUITE 20 RK 10 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441315032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166368052 | ||||||||
| FaxNumber: | 2166368088 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441227024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164916000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONGVILLE | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCT. OFFICER AND CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2166367416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1297 | OH | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100120 | 01 | OH | KAISER | OTHER | 8552507 | 05 | OH | MEDICAID | 340811464-00 | 01 | OH | BUREAU WORKERS COMPENSATI | OTHER | 5000056 | 01 | OH | UNITED HEALTH CARE | OTHER | 000000157027 | 01 | OH | ANTHEM | OTHER | 0062834 | 01 | OH | AETNA | OTHER |