Healthcare Provider Details

I. General information

NPI: 1326230764
Provider Name (Legal Business Name): MARYMOUNT PRIMARY CARE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34501 AURORA RD SUITE 101
SOLON OH
44139-3873
US

IV. Provider business mailing address

34501 AURORA RD SUITE 101
SOLON OH
44139-3873
US

V. Phone/Fax

Practice location:
  • Phone: 440-914-0960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

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