=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356530943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES O. MBANEFO, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2007
-----------------------------------------------------
Last Update Date | 10/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11201 SHAKER BLVD SUITE 130
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44104-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-368-5687
-----------------------------------------------------
Fax | 216-368-5623
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11201 SHAKER BLVD SUITE 130
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44104-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-368-5687
-----------------------------------------------------
Fax | 216-368-5623
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHARLES O. MBANEFO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 216-368-5687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35-05-1577M
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------