Healthcare Provider Details

I. General information

NPI: 1497884605
Provider Name (Legal Business Name): UNIVERSITY PRIMARY CARE PRACTICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E WASHINGTON ST STE 100
MEDINA OH
44256-3331
US

IV. Provider business mailing address

PO BOX 772040
DETROIT MI
48277-2040
US

V. Phone/Fax

Practice location:
  • Phone: 330-721-8474
  • Fax: 216-201-8952
Mailing address:
  • Phone: 216-383-6480
  • Fax: 216-383-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JANNA M KENNEDY
Title or Position: DIRECTOR MED STAFF SERVICES & CRED
Credential:
Phone: 216-844-2045