Healthcare Provider Details

I. General information

NPI: 1003672288
Provider Name (Legal Business Name): DERRICK SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2114 NOBLE RD
CLEVELAND OH
44112-1725
US

IV. Provider business mailing address

2114 NOBLE RD
CLEVELAND OH
44112-1725
US

V. Phone/Fax

Practice location:
  • Phone: 216-268-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: