=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578744116
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEVELAND CENTER FOR JOINT RECONSTRUCTION, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2007
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1730 W 25TH ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44113-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-363-2096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6896 W SNOWVILLE RD
-----------------------------------------------------
City | BRECKSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44141-3214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED REPRESENTATIVE
-----------------------------------------------------
Name | DR. BERNARD STULBERG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 216-363-2096
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------