Healthcare Provider Details

I. General information

NPI: 1780816819
Provider Name (Legal Business Name): UNIVERSITY HOSPITALS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12340 BASS LAKE RD
CHARDON OH
44024-8327
US

IV. Provider business mailing address

3605 WARRENSVILLE CENTER RD 1ST FLOOR
SHAKER HTS OH
44122-5203
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-4040
  • Fax: 440-285-7278
Mailing address:
  • Phone: 216-286-6260
  • Fax: 216-286-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: LARRY MCELROY
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 216-767-8717