Healthcare Provider Details

I. General information

NPI: 1770765380
Provider Name (Legal Business Name): OUTREACH PROFESSIONAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33141 BAINBRIDGE RD
SOLON OH
44139
US

IV. Provider business mailing address

26908 DETROIT RD SUITE 301
WESTLAKE OH
44145-2398
US

V. Phone/Fax

Practice location:
  • Phone: 440-248-8888
  • Fax: 440-349-4026
Mailing address:
  • Phone: 440-617-1823
  • Fax: 440-617-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

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