MEDICARE: CLEVELAND STATE UNIVERSITY

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	261QS1000X	Student Health Clinic/Center

General Provider Information

NPI Number	:	1164704995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	PO BOX 819020
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75381-9020
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2214
Country	:	US
Telephone Number	:	216-687-5287
Fax Number	:

Authorized Official
Title or Position	:	HEAD ATHLETICS TRAINER
Name	:	CHRIS LACSAMANA
Credential	:
Telephone Number	:	216-687-5287

Provider Enumeration Date	:	09/19/2011
Last Update Date	:	09/19/2011

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Directions to “CLEVELAND STATE UNIVERSITY ” Practice Location

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