Healthcare Provider Details

I. General information

NPI: 1114958774
Provider Name (Legal Business Name): SYCAMORE CREEK HEALTHCARE GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 CORAOPOLIS RD
CORAOPOLIS PA
15108-4004
US

IV. Provider business mailing address

23700 COMMERCE PARK
BEACHWOOD OH
44122-5827
US

V. Phone/Fax

Practice location:
  • Phone: 412-331-6060
  • Fax:
Mailing address:
  • Phone: 216-292-5706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number198602
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1016337900001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: WILLIAM I WEISBERG
Title or Position: PRESIDENT
Credential: NHA
Phone: 216-292-5706