MEDICARE: UNIVERSITY HOSPITALS MEDICAL GROUP, 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	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1780808790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY HOSPITALS MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	PO BOX 772044
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48277-2044
Country	:	US
Telephone Number	:	440-732-3923
Fax Number	:

Provider Business Practice Location Address
First Line	:	3909 ORANGE PL STE 4100
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-4480
Country	:	US
Telephone Number	:	440-732-3923
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF MED STAFF SERVICES
Name	:	JANNA M KENNEDY
Credential	:
Telephone Number	:	330-996-8671

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	02/23/2021

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