MEDICARE: OUTREACH PROFESSIONAL SERVICES 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	207R00000X	Internal Medicine Physician
2	208600000X	Surgery 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	:	1780866467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUTREACH PROFESSIONAL SERVICES INC

Provider Business Mailing Address
First Line	:	26908 DETROIT RD
Second Line	:	SUITE 301
City	:	WESTLAKE
State	:	OH
Zip	:	44145-2398
Country	:	US
Telephone Number	:	440-617-1823
Fax Number	:	440-617-0884

Provider Business Practice Location Address
First Line	:	2322 EAST 22ND ST
Second Line	:	SUITE 207
City	:	CLEVELAND
State	:	PA
Zip	:	44145
Country	:	US
Telephone Number	:	216-592-2801
Fax Number	:	216-592-2811

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MISTY A BLAYLOCK
Credential	:
Telephone Number	:	440-892-6406

Provider Enumeration Date	:	12/04/2007
Last Update Date	:	01/12/2010

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Directions to “OUTREACH PROFESSIONAL SERVICES INC ” Practice Location

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