Healthcare Provider Details

I. General information

NPI: 1538748611
Provider Name (Legal Business Name): ALBERT A CIVITARESE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # NA-23
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE # NA-23
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-2200
  • Fax:
Mailing address:
  • Phone: 216-444-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34.017335
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: