Basic Information
Provider Information | |||||||||
NPI: | 1679897359 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY HOSPITALS MEDICAL GROUP, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
Address2: | OFFICE 1342 | ||||||||
City: | SHAKER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441225203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162866296 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Practice Location | |||||||||
Address1: | 18599 LAKE SHORE BLVD | ||||||||
Address2: | SUITE 111 | ||||||||
City: | EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 441191093 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162866296 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2010 | ||||||||
LastUpdateDate: | 03/24/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCELROY | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 2163836756 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X |   | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X |   | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 2691903 | 05 | OH |   | MEDICAID |