Basic Information
| Provider Information | |||||||||
| NPI: | 1487968186 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY HOSPITALS MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 24701EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836616 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | B402 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168443941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2010 | ||||||||
| LastUpdateDate: | 08/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2163836756 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2691903 | 05 | OH | MEDICAID |