Healthcare Provider Details

I. General information

NPI: 1326265000
Provider Name (Legal Business Name): MARYMOUNT PRIMARY CARE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 ROCKSIDE RD SUITE 2100
INDEPENDENCE OH
44131-2109
US

IV. Provider business mailing address

4400 ROCKSIDE RD SUITE 2100
INDEPENDENCE OH
44131-2109
US

V. Phone/Fax

Practice location:
  • Phone: 216-573-1300
  • Fax: 216-503-5005
Mailing address:
  • Phone: 216-573-1300
  • Fax: 216-503-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER P WALCHANOWICZ
Title or Position: PRACTICE MANAGER
Credential:
Phone: 440-543-8855