MEDICARE: SOUTH VIENNA GROUP HOMES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104038637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH VIENNA GROUP HOMES, INC.

Provider Business Mailing Address
First Line	:	22021 BROOKPARK RD
Second Line	:	STE 123
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-3100
Country	:	US
Telephone Number	:	440-614-0160
Fax Number	:	440-614-0168

Provider Business Practice Location Address
First Line	:	125 EAST NATIONAL ROAD
Second Line	:
City	:	SOUTH VIENNA
State	:	OH
Zip	:	45369-9742
Country	:	US
Telephone Number	:	937-568-4342
Fax Number	:	937-568-4265

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN COLLERAN
Credential	:
Telephone Number	:	440-614-0160

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	10/22/2007

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