Basic Information
Provider Information | |||||||||
NPI: | 1386696847 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLEVELAND CLINIC HEALTH SYSTEM - EAST REGION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HURON HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6801 BRECKSVILLE RD | ||||||||
Address2: | SUITE 20 RK 10 | ||||||||
City: | INDEPENDENCE | ||||||||
State: | OH | ||||||||
PostalCode: | 441315032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2166368052 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13951 TERRACE RD | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441124308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2167613300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 01/12/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GLASS | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2164449361 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1148 | OH | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 4195517 | 05 | OH |   | MEDICAID | 100119 | 01 | OH | KAISER | OTHER | 000000157025 | 01 | OH | ANTHEM | OTHER | 340714435-00 | 01 | OH | BUREAU WORKERS COMPENSATI | OTHER | 0081812 | 01 | OH | AETNA | OTHER | 5000055 | 01 | OH | UNITED HEALTHCARE | OTHER |