=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992179493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY PRIMARY CARE PRACTICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2015
-----------------------------------------------------
Last Update Date | 11/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9318 STATE ROUTE 14 1ST FLOOR
-----------------------------------------------------
City | STREETSBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44241-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-626-3455
-----------------------------------------------------
Fax | 330-626-4189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8792
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-8792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-626-3455
-----------------------------------------------------
Fax | 330-626-4189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR BUSINESS OPERATIONS ANALYST
-----------------------------------------------------
Name | GABRIEL E LADER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-358-2348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------