Basic Information
| Provider Information | |||||||||
| NPI: | 1457308207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | URBAN | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16930 GLEN RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430509501 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1730 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441133108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166964300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | 35049954 | OH | Y | Emergency Medical Service Providers | Personal Emergency Response Attendant |
ID Information
| ID | Type | State | Issuer | Description | P00220796 | 01 | OH | MEDICARE TRAVELERS RR-GA | OTHER | 942460636052 | 01 | OH | CARESOURCE | OTHER | 0585915 | 05 | OH | MEDICAID |