Basic Information
Provider Information | |||||||||
NPI: | 1942248737 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARYMOUNT HOSPITAL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARYMOUNT HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12300 MCCRACKEN ROAD | ||||||||
Address2: |   | ||||||||
City: | GARFIELD HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441252914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2165810500 | ||||||||
FaxNumber: | 2166368088 | ||||||||
Practice Location | |||||||||
Address1: | 12300 MCCRACKEN ROAD | ||||||||
Address2: |   | ||||||||
City: | GARFIELD HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441252914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2165810500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 03/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONGVILLE | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ACCT. OFFICER AND CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 2166367416 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1136 | OH | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 000000157008 | 01 |   | ANTHEM | OTHER | 5000046 | 01 |   | UNITED HEALTHCARE | OTHER | 5575800 | 05 | OH |   | MEDICAID | 6460670 | 01 |   | AETNA | OTHER | 100107 | 01 | OH | KAISER | OTHER |