Healthcare Provider Details

I. General information

NPI: 1235127408
Provider Name (Legal Business Name): CLINIC PHYSICIAN SERVICES CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 MAYFIELD RD
MAYFIELD HTS OH
44124-2203
US

IV. Provider business mailing address

6801 BRECKSVILLE RD RK1-19
INDEPENDENCE OH
44131-5032
US

V. Phone/Fax

Practice location:
  • Phone: 440-312-4500
  • Fax:
Mailing address:
  • Phone: 216-442-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TIM LONGVILLE
Title or Position: CHIEF ACCOUNTING OFFICER AND CONTRO
Credential:
Phone: 216-636-7416