Basic Information
| Provider Information | |||||||||
| NPI: | 1447575543 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HOSPITALS MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | OFFICE 1342 | ||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866296 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 CLAGUE RD | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441451582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866296 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2163836756 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207RG0100X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207LP2900X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2691903 | 05 | OH | MEDICAID |