Healthcare Provider Details

I. General information

NPI: 1053942904
Provider Name (Legal Business Name): MARVIN SAMUELS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 LEE BLVD # 200-9
CLEVELAND HEIGHTS OH
44118-1268
US

IV. Provider business mailing address

1606 LACLEDE RD
SOUTH EUCLID OH
44121-3014
US

V. Phone/Fax

Practice location:
  • Phone: 226-352-7959
  • Fax:
Mailing address:
  • Phone: 216-352-7959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: