Healthcare Provider Details

I. General information

NPI: 1306931316
Provider Name (Legal Business Name): SALLY NAMBOODIRI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4242 LORAIN AVE
CLEVELAND OH
44113-3715
US

IV. Provider business mailing address

4242 LORAIN AVE
CLEVELAND OH
44113-3715
US

V. Phone/Fax

Practice location:
  • Phone: 216-939-0699
  • Fax: 216-939-0789
Mailing address:
  • Phone: 216-939-0699
  • Fax: 216-939-0789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number35063103
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: