Healthcare Provider Details

I. General information

NPI: 1275852253
Provider Name (Legal Business Name): NICHOLAS KOEPPEN EILBECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10524 EUCLID AVE W.O. WALKER CENTER, 8TH FLOOR
CLEVELAND OH
44106-2205
US

IV. Provider business mailing address

10524 EUCLID AVE W.O. WALKER CENTER, 8TH FLOOR
CLEVELAND OH
44106-2205
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-1000
  • Fax:
Mailing address:
  • Phone: 216-844-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.120556
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35.120556
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: