Basic Information
| Provider Information | |||||||||
| NPI: | 1962618975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOMEISL | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | DEPARTMENT OF PATHOLOGY | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168441000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 03/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0006X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZC0500X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZF0201X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology | 207ZH0000X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZI0100X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Immunopathology | 207ZM0300X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | 207ZN0500X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZP0007X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Molecular Genetic Pathology | 207ZP0101X | 34-009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0104X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Chemical Pathology | 207ZP0105X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0213X | 34009118 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 207ZB0001X | 34009118 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2978372 | 05 | OH | MEDICAID |