Basic Information
Provider Information | |||||||||
NPI: | 1669603676 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LARRY MCELROY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24701 EUCLID AVE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 441171714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163836616 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5133 RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | WADSWORTH | ||||||||
State: | OH | ||||||||
PostalCode: | 442819708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168443118 | ||||||||
FaxNumber: | 2168443126 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2009 | ||||||||
LastUpdateDate: | 01/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCELROY | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2167678717 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X |   | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 208000000X |   | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 208800000X |   | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   | 2085R0202X |   | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 2691903 | 05 | OH |   | MEDICAID |