Basic Information
| Provider Information | |||||||||
| NPI: | 1568426427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARDELT | ||||||||
| FirstName: | AGNIESZKA | ||||||||
| MiddleName: | ANNA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARDELT | ||||||||
| OtherFirstName: | AGNIESZKA | ||||||||
| OtherMiddleName: | ANNA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 METROHEALTH DR | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167787800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 METROHEALTH DR | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167787800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036122485 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 35132213 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084V0102X | 35132213 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084V0102X | 036122485 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084A2900X | 35132213 | OH | Y |
ID Information
| ID | Type | State | Issuer | Description | 051534611 | 01 | AL | BLUE CROSS | OTHER | 009937034 | 05 | AL | MEDICAID | 009937033 | 05 | AL | MEDICAID | 051534612 | 01 | AL | BLUE CROSS | OTHER |