Basic Information
| Provider Information | |||||||||
| NPI: | 1356650493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUTREACH PROFESSIONAL SERVICE, INC. | ||||||||
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| OtherOrganizationName: | CUYAHOGA PHYSICIAN NETWORK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26908 DETROIT RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406171823 | ||||||||
| FaxNumber: | 4406170884 | ||||||||
| Practice Location | |||||||||
| Address1: | 2322 E 22ND ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163632732 | ||||||||
| FaxNumber: | 2163633304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2010 | ||||||||
| LastUpdateDate: | 10/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | BLAYLOCK | ||||||||
| AuthorizedOfficialFirstName: | MISTY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4408926406 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 0251856 | 05 | OH | MEDICAID |