MEDICARE: NORTH SHORE DIAGNOSTIC, 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	207Q00000X	Family Medicine Physician

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	:	1649213919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SHORE DIAGNOSTIC, INC.

Provider Business Mailing Address
First Line	:	21055 LORAIN RD
Second Line	:
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-2126
Country	:	US
Telephone Number	:	440-409-0041
Fax Number	:	440-409-0042

Provider Business Practice Location Address
First Line	:	21055 LORAIN RD
Second Line	:
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-2126
Country	:	US
Telephone Number	:	440-409-0041
Fax Number	:	440-409-0042

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KIM H SELTZER
Credential	:
Telephone Number	:	440-409-0041

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	08/22/2020

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