Healthcare Provider Details

I. General information

NPI: 1609186204
Provider Name (Legal Business Name): OUTREACH PROFESSIONAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 ROCKSIDE ROAD SUITE 2200
INDEPENDENCE OH
44131
US

IV. Provider business mailing address

26908 DETROIT ROAD SUITE 301
WESTLAKE OH
44145
US

V. Phone/Fax

Practice location:
  • Phone: 216-363-7075
  • Fax: 216-624-7592
Mailing address:
  • Phone: 440-617-1823
  • Fax: 440-617-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MISTY A BLAYLOCK
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 440-892-6406