MEDICARE: CLEVELAND CLINIC SPORTS HEALTH CENTER

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	261QR0400X	Rehabilitation Clinic/Center	AT. 004124	OH

General Provider Information

NPI Number	:	1740616820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND CLINIC SPORTS HEALTH CENTER

Provider Business Mailing Address
First Line	:	4683 WAYNE RD
Second Line	:
City	:	MANTUA
State	:	OH
Zip	:	44255-9664
Country	:	US
Telephone Number	:	330-274-8396
Fax Number	:

Provider Business Practice Location Address
First Line	:	4683 WAYNE ROAD
Second Line	:
City	:	MANTUA
State	:	OH
Zip	:	44255
Country	:	US
Telephone Number	:	330-274-8396
Fax Number	:

Authorized Official
Title or Position	:	COORDINATOR OF AT
Name	:	GARY MILLER
Credential	:
Telephone Number	:	216-518-3429

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/19/2013

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