Basic Information
| Provider Information | |||||||||
| NPI: | 1518985126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATGOURANIS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866260 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35-054222 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 221083 | 01 | OH | UNISON | OTHER | 363815 | 01 | OH | WELLCARE MEDICAID | OTHER | P00027153 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000221083 | 01 | OH | UNISON | OTHER | 747464 | 01 | OH | BUCKEYE MEDICAID | OTHER | 200972660A | 05 | IN | MEDICAID | 000000516047 | 01 | OH | ANTHEM | OTHER | 0583328 | 01 | OH | BCMH | OTHER | 0680651 | 05 | OH | MEDICAID | P00398034 | 01 | OH | RAILROAD MEDICARE | OTHER | 4397616 | 01 | OH | AETNA | OTHER |