=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063147361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. VINCENT CHARITY HEALTH CAMPUS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2022
-----------------------------------------------------
Last Update Date | 02/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2351 E 22ND ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-363-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2475 E 22ND ST FL 5
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-363-7010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, BEHAVIORAL HEALTH
-----------------------------------------------------
Name | DR. MICHAEL J BISCARO
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 216-363-7010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------