MEDICARE: MIEYA JANETTE IDOM

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1508563628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIEYA JANETTE IDOM

Provider Business Mailing Address
First Line	:	2286 N TAYLOR RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44112-3046
Country	:	US
Telephone Number	:	216-315-8447
Fax Number	:

Provider Business Practice Location Address
First Line	:	2286 N TAYLOR RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44112-3046
Country	:	US
Telephone Number	:	216-315-8447
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2023
Last Update Date	:	02/09/2023

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Directions to “ MIEYA JANETTE IDOM ” Practice Location

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