Healthcare Provider Details

I. General information

NPI: 1164726360
Provider Name (Legal Business Name): BIRCHCREST HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 RICHMOND RD STE 300
CLEVELAND OH
44128
US

IV. Provider business mailing address

4760 RICHMOND RD STE 300
CLEVELAND OH
44128-5979
US

V. Phone/Fax

Practice location:
  • Phone: 216-765-8390
  • Fax: 216-765-8392
Mailing address:
  • Phone: 216-765-8390
  • Fax: 216-765-8392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACK CORNELL
Title or Position: PRESIDENT
Credential:
Phone: 216-765-8390