Basic Information
| Provider Information | |||||||||
| NPI: | 1316206360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND CLINIC FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLEVELAND CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6000 W CREEK RD | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441312182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164442200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164442200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDVE | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2169733321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0064907 | 05 | OH | MEDICAID |