Healthcare Provider Details

I. General information

NPI: 1609884592
Provider Name (Legal Business Name): ST JUDES MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7211 BROADWAY
CLEVELAND OH
44105
US

IV. Provider business mailing address

7211 BROADWAY
CLEVELAND OH
44105
US

V. Phone/Fax

Practice location:
  • Phone: 216-271-1947
  • Fax: 216-271-0106
Mailing address:
  • Phone: 216-271-1947
  • Fax: 216-271-0106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35033404
License Number StateOH

VIII. Authorized Official

Name: DR. NELIDA R ENRIQUE
Title or Position: PRESIDENT TREASURER
Credential: MD
Phone: 216-271-1947