Basic Information
Provider Information | |||||||||
NPI: | 1790704336 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIU | ||||||||
FirstName: | WENDY | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
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: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11100 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441061716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168447494 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 08/18/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 35-082840 | OH | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0101X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZB0001X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZC0006X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZP0105X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZC0500X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZF0201X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology | 207ZH0000X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZI0100X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Immunopathology | 207ZM0300X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | 207ZP0007X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Molecular Genetic Pathology | 207ZN0500X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZP0213X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 207ZP0104X | 35-082840 | OH | N |   | Allopathic & Osteopathic Physicians | Pathology | Chemical Pathology |
ID Information
ID | Type | State | Issuer | Description | 000000340225 | 01 | OH | ANTHEM | OTHER | 744714 | 01 | OH | BUCKEYE | OTHER | 1790704336 | 01 | MI | MI MEDICAID | OTHER | 000000528793 | 01 | OH | ANTHEM | OTHER | 2434511 | 05 | OH |   | MEDICAID | 363777 | 01 | OH | WELLCARE | OTHER | 7211499 | 01 | OH | AETNA | OTHER | P00412499 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000221126 | 01 | OH | UNISON | OTHER | 0127464 | 01 | OH | BCMH | OTHER | P00139036 | 01 | OH | RAILROAD MEDICARE | OTHER |