=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609119510
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN M MEDRICK D.O,
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2013
-----------------------------------------------------
Last Update Date | 09/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44195-6805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-476-7160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 E SPRAGUE RD
-----------------------------------------------------
City | SEVEN HILLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44131-6138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-655-3842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 34.013350
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 34.013350
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------