Basic Information
| Provider Information | |||||||||
| NPI: | 1790169381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT CHARITY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19425 VAN AKEN BLVD | ||||||||
| Address2: | APT. 401 | ||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441223547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168616200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2351 E 22ND ST | ||||||||
| Address2: | SUITE 342W | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168616200 | ||||||||
| FaxNumber: | 2163637490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOLT | ||||||||
| AuthorizedOfficialFirstName: | DYRON | ||||||||
| AuthorizedOfficialMiddleName: | MICKEY | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTAL RESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8652508398 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.