=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083047054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY HOSPITALS HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2013
-----------------------------------------------------
Last Update Date | 08/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11100 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44106-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 121-684-4279
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7398 CADLE AVE
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-5709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CNP
-----------------------------------------------------
Name | JAMIE ALLISON WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 12168442798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | RN279047
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------