Basic Information
| Provider Information | |||||||||
| NPI: | 1518003284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYMOUNT SPECIAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 72083 | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441920002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408790081 | ||||||||
| FaxNumber: | 4408790084 | ||||||||
| Practice Location | |||||||||
| Address1: | 12300 MCCRACKEN RD | ||||||||
| Address2: | |||||||||
| City: | GARFIELD HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441252914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165878867 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KHOURY | ||||||||
| AuthorizedOfficialFirstName: | WAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD OF CARDIOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 2164755370 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0509702 | 05 | OH | MEDICAID |