Basic Information
| Provider Information | |||||||||
| NPI: | 1346919362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE METROHEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | METROHEALTH BROADWAY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 METROHEALTH DR | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167787800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6835 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441051313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169571850 | ||||||||
| FaxNumber: | 2169571695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2021 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VALENZENO | ||||||||
| AuthorizedOfficialFirstName: | BRITTANY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER, MEDICAL STAFF OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 2167781639 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE METROHEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.