MEDICARE: CLEVELAND ASC LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	0448AS	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	490003603	OTHER	OH	RAILROAD MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1417937756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND ASC LLC

Provider Business Mailing Address
First Line	:	15933 CLAYTON RD STE 210
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-2172
Country	:	US
Telephone Number	:	636-227-2600
Fax Number	:

Provider Business Practice Location Address
First Line	:	5106 WILSON MILLS RD
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	OH
Zip	:	44143-3006
Country	:	US
Telephone Number	:	440-461-2570
Fax Number	:	440-461-7109

Authorized Official
Title or Position	:	CHIEF MEDICAL OFFICER
Name	:	JAMES WACHTER
Credential	:
Telephone Number	:	636-227-2600

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	04/20/2023

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Directions to “CLEVELAND ASC LLC ” Practice Location

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