Healthcare Provider Details

I. General information

NPI: 1306608203
Provider Name (Legal Business Name): QUEENPHILLYCORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13807 UNION AVE
CLEVELAND OH
44120-4520
US

IV. Provider business mailing address

13807 UNION AVE
CLEVELAND OH
44120-4520
US

V. Phone/Fax

Practice location:
  • Phone: 216-482-0152
  • Fax:
Mailing address:
  • Phone: 216-482-0152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS MICHELLE GILL
Title or Position: TRANSPORTATION
Credential:
Phone: 216-482-0152