Basic Information
| Provider Information | |||||||||
| NPI: | 1285877225 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HOSPITALS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | MSC 9152 | ||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 CLAGUE RD | ||||||||
| Address2: | BLDG B | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441451503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2009 | ||||||||
| LastUpdateDate: | 06/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2167678717 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207SG0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 2691903 | 05 | OH | MEDICAID |