=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184237968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER CLEVELAND PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2020
-----------------------------------------------------
Last Update Date | 08/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3311 RICHMOND RD
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-4195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-562-3772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2956 WASHINGTON BLVD
-----------------------------------------------------
City | CLEVELAND HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44118-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-562-3772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. KEILI MISTOVICH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 614-562-3772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------