Basic Information
Provider Information | |||||||||
NPI: | 1497945216 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCIALLIS | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | GAMMA KNIFE CENTER | ||||||||
Address2: | 9410 CARNEGIE AVENUE | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 44106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2164457695 | ||||||||
FaxNumber: | 2164448238 | ||||||||
Practice Location | |||||||||
Address1: | 9500 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441955054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2164442200 | ||||||||
FaxNumber: | 2164448238 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2007 | ||||||||
LastUpdateDate: | 04/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 4301103725 | MI | N |   | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0101X | 4301103725 | MI | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | 51263 | MN | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 4301103725 | MI | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207ZP0102X | 35.143834 | OH | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | ENROLLED | 05 | MN |   | MEDICAID |