Basic Information
| Provider Information | |||||||||
| NPI: | 1639143449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UHHS/CSAHS - CUYAHOGA, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST JOHN WEST SHORE DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6935 TREELINE DR | ||||||||
| Address2: | SUITE J | ||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441413393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407463401 | ||||||||
| FaxNumber: | 4407463405 | ||||||||
| Practice Location | |||||||||
| Address1: | 29000 CENTER RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408358000 | ||||||||
| FaxNumber: | 4407463405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TRACY | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2164364653 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 000000157498 | 01 | ANTHEM | OTHER |