Healthcare Provider Details

I. General information

NPI: 1902097751
Provider Name (Legal Business Name): MARYMOUNT PRIMARY CARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 ROCKSIDE RD SUITE 260
INDEPENDENCE OH
44131-2358
US

IV. Provider business mailing address

6701 ROCKSIDE RD SUITE 260
INDEPENDENCE OH
44131-2358
US

V. Phone/Fax

Practice location:
  • Phone: 216-369-2525
  • Fax: 216-369-2531
Mailing address:
  • Phone: 216-369-2525
  • Fax: 216-369-2531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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