=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982805917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY PRIMARY CARE PRACTICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2007
-----------------------------------------------------
Last Update Date | 04/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 7TH AVE STE 110
-----------------------------------------------------
City | CHARDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44024-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-286-8841
-----------------------------------------------------
Fax | 440-286-8867
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 74557
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44194-0640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-383-0100
-----------------------------------------------------
Fax | 216-383-6745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF BILLING SERVICES
-----------------------------------------------------
Name | MR. STEVE RIDDLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-383-6480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------