=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750314662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER ALEXANDER DEGOLIA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 03/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11100 EUCLID AVENUE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-844-3944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3605 WARRENSVILLE CENTER RD 1ST FLOOR
-----------------------------------------------------
City | SHAKER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-286-6295
-----------------------------------------------------
Fax | 216-286-6341
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 35062016
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------