=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053682690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST VINCENT CHARITY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2012
-----------------------------------------------------
Last Update Date | 01/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 E 13TH ST APT 21X
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44114-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-420-9744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 E 13TH ST APT 21X
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44114-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-420-9744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | KEYVAN RAVAKAHN
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 216-363-2715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 57019192
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------