Healthcare Provider Details

I. General information

NPI: 1023089653
Provider Name (Legal Business Name): MARYMOUNT PRIMARY CARE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17747 CHILLICOTHE RD SUITE 100
CHAGRIN FALLS OH
44023-4739
US

IV. Provider business mailing address

17747 CHILLICOTHE RD SUITE 100
CHAGRIN FALLS OH
44023-4739
US

V. Phone/Fax

Practice location:
  • Phone: 440-543-8855
  • Fax: 440-543-2470
Mailing address:
  • Phone: 440-543-8855
  • Fax: 440-543-2470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER P WALCHANOWICZ
Title or Position: PRACTICE MANAGER
Credential:
Phone: 440-543-8855