Basic Information
| Provider Information | |||||||||
| NPI: | 1467427518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY HOSPITALS ST. JOHN MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UH ST. JOHN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6935 TREELINE DR | ||||||||
| Address2: | SUITE J | ||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441413393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407463401 | ||||||||
| FaxNumber: | 4407463405 | ||||||||
| Practice Location | |||||||||
| Address1: | 29000 CENTER RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408358000 | ||||||||
| FaxNumber: | 4407463405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | VEHOVEC | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP & CORPORATE CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2167678729 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST JOHN MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 34189345207 | 01 | OH | BUREAU OF WORKERS COMPENS | OTHER | 2137422 | 05 | OH | MEDICAID | 341893452013 | 01 | OH | MEDICAL MUTUAL OF OHIO | OTHER | 000000157548 | 01 | ANTHEM | OTHER |