Healthcare Provider Details

I. General information

NPI: 1215280029
Provider Name (Legal Business Name): EATING DISORDER MEDICAL SPECIALISTS OF CLEVELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25550 CHAGRIN BLVD 207
BEACHWOOD OH
44122-5638
US

IV. Provider business mailing address

25550 CHAGRIN BLVD 207
BEACHWOOD OH
44122-5638
US

V. Phone/Fax

Practice location:
  • Phone: 216-765-0500
  • Fax: 216-765-0521
Mailing address:
  • Phone: 216-765-0500
  • Fax: 216-765-0521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35083837
License Number StateOH

VIII. Authorized Official

Name: MACHELLE GIORDON
Title or Position: CREDENTIALING
Credential:
Phone: 330-723-2111