Basic Information
| Provider Information | |||||||||
| NPI: | 1477855153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HOSPITALS MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 29001 CEDAR RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LYNDHURST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441244062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404617999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2010 | ||||||||
| LastUpdateDate: | 12/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2163836616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 207RG0100X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2691903 | 05 | OH | MEDICAID |