Basic Information
Provider Information | |||||||||
NPI: | 1871794073 | ||||||||
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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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
Address2: | MSC9152 | ||||||||
City: | SHAKER HTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441225203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162866299 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Practice Location | |||||||||
Address1: | 29001 CEDAR RD | ||||||||
Address2: | STE 203 | ||||||||
City: | LYNDHURST | ||||||||
State: | OH | ||||||||
PostalCode: | 441244062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168441000 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2007 | ||||||||
LastUpdateDate: | 11/06/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCELROY | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2168446217 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   | 207W00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 2691903 | 05 | OH |   | MEDICAID | 5972910002 | 01 | OH | DMERC | OTHER |