Basic Information
Provider Information | |||||||||
NPI: | 1275566184 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAETZ-GREENWALT | ||||||||
FirstName: | BARBARA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5910 LANDERBROOK DR | ||||||||
Address2: | SUITE 250 | ||||||||
City: | MAYFIELD HTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441246508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4406845829 | ||||||||
FaxNumber: | 4404491555 | ||||||||
Practice Location | |||||||||
Address1: | 11100 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441061716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168447700 | ||||||||
FaxNumber: | 4404491555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 35-045792 | OH | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
ID | Type | State | Issuer | Description | 0656535 | 05 | OH |   | MEDICAID | 5429031 | 01 | OH | AETNA | OTHER | 80063 | 01 | OH | QUALCHOICE | OTHER | 1201917 | 01 | OH | UHC | OTHER | 000000026882 | 01 | OH | ANTHEM | OTHER |