Basic Information
| Provider Information | |||||||||
| NPI: | 1710951801 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST VINCENT CHARITY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST VINCENT CHARITY MEDICAL CENTER | ||||||||
| 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: | 2351 E 22ND ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168616200 | ||||||||
| FaxNumber: | 4407463405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | RUSNACZYK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2163637718 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 34189345202 | 01 | OH | BUREAU WORKERS' COMPENSAT | OTHER | 016984000 | 01 | MAGELLAN BEHAVIORAL HLTH | OTHER | 2137410001 | 01 | OH | CARESOURCE | OTHER | 3009523 | 05 | OH | MEDICAID | 0009438 | 01 | AETNA US HEALTHCARE | OTHER | 000000157500 | 01 | ANTHEM | OTHER | 341893452001 | 01 | CHAMPUS | OTHER | 7649709 | 01 | OH | PEOPLES HEALTH PLAN | OTHER | 34189342007 | 01 | OH | MEDICAL MUTUAL OF OHIO CD | OTHER | 341893452005 | 01 | OH | MEDICAL MUTUAL OF OHIO | OTHER | 5000072 | 01 | UNITED HEALTHCARE | OTHER | 615124400 | 01 | DEPARTMENT OF LABOR | OTHER | 7649709 | 05 | OH | MEDICAID | 304978 | 01 | BLACK LUNG | OTHER | 81312 | 01 | OH | QUALCHOICE | OTHER |