MEDICARE: CUYAHOGA COUNTY BD OF MRDD

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	1815532	OH

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	:	1649484742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUYAHOGA COUNTY BD OF MRDD

Provider Business Mailing Address
First Line	:	1275 LAKESIDE AVE E
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44114-1132
Country	:	US
Telephone Number	:	216-736-2625
Fax Number	:	216-736-2702

Provider Business Practice Location Address
First Line	:	9401 MEMPHIS AVE
Second Line	:
City	:	BROOKLYN
State	:	OH
Zip	:	44144-2030
Country	:	US
Telephone Number	:	216-736-2625
Fax Number	:	216-736-2702

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	MR. TERRENCE RYAN
Credential	:
Telephone Number	:	216-736-2625

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	08/22/2020

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