Basic Information
| Provider Information | |||||||||
| NPI: | 1679511463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYMOUNT HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MARYMOUNT HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12300 MCCRACKEN ROAD | ||||||||
| Address2: | |||||||||
| City: | GARFIELD HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441252914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165810500 | ||||||||
| FaxNumber: | 2166368088 | ||||||||
| Practice Location | |||||||||
| Address1: | 12300 MCCRACKEN ROAD | ||||||||
| Address2: | |||||||||
| City: | GARFIELD HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441252914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165810500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONGVILLE | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCT. OFFICER AND CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2166367416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 1136 | OH | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 2915171 | 05 | OH | MEDICAID | 5000046 | 01 | UNITED HEALTHCARE | OTHER | 100107 | 01 | KAISER | OTHER | 6460670 | 01 | AETNA | OTHER |