Healthcare Provider Details

I. General information

NPI: 1063530236
Provider Name (Legal Business Name): UNIVERSITY PRIMARY CARE PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E ROYALTON RD STE 100
BROADVIEW HTS OH
44147-2592
US

IV. Provider business mailing address

PO BOX 74610
CLEVELAND OH
44194-0693
US

V. Phone/Fax

Practice location:
  • Phone: 216-383-0100
  • Fax: 216-383-6481
Mailing address:
  • Phone: 216-383-6480
  • Fax: 216-383-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVE RIDDLE
Title or Position: DIRECTOR OF BILLING SERVICES
Credential:
Phone: 216-383-6480