Healthcare Provider Details

I. General information

NPI: 1992958227
Provider Name (Legal Business Name): MARYMOUNT CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 07/24/2009
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:
Mailing address:
  • Phone: 440-543-8855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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