Healthcare Provider Details

I. General information

NPI: 1386697621
Provider Name (Legal Business Name): WEST SIDE CARDIOLOGY ASSOC., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20455 LORAIN RD SECOND FLOOR
FAIRVIEW PARK OH
44126-3494
US

IV. Provider business mailing address

20455 LORAIN RD SECOND FLOOR
FAIRVIEW PARK OH
44126-3494
US

V. Phone/Fax

Practice location:
  • Phone: 440-333-8600
  • Fax: 440-333-5015
Mailing address:
  • Phone: 440-333-8600
  • Fax: 440-333-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: MARCELLO M. MELLINO
Title or Position: PRESIDENT
Credential: MD
Phone: 440-333-8600