MEDICARE: MARYMOUNT PRIMARY CARE SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000564045	OTHER	OH	ANTHEM

General Provider Information

NPI Number	:	1063606440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYMOUNT PRIMARY CARE SERVICES, INC.

Provider Business Mailing Address
First Line	:	2001 E ROYALTON RD
Second Line	:
City	:	BROADVIEW HEIGHTS
State	:	OH
Zip	:	44147-2811
Country	:	US
Telephone Number	:	440-717-6100
Fax Number	:	440-546-1382

Provider Business Practice Location Address
First Line	:	2001 E ROYALTON RD
Second Line	:
City	:	BROADVIEW HEIGHTS
State	:	OH
Zip	:	44147-2811
Country	:	US
Telephone Number	:	440-717-6100
Fax Number	:	440-546-1382

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	PETER P WALCHANOWICZ
Credential	:
Telephone Number	:	440-543-8855

Provider Enumeration Date	:	08/29/2007
Last Update Date	:	05/27/2008

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