MEDICARE: RETINA ASSOCIATES OF CLEVELAND

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	363A00000X	Physician Assistant	50.002593	OH

General Provider Information

NPI Number	:	1841697463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA ASSOCIATES OF CLEVELAND

Provider Business Mailing Address
First Line	:	3401 ENTERPRISE PKWY STE 300
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-7340
Country	:	US
Telephone Number	:	216-831-5700
Fax Number	:	216-831-1959

Provider Business Practice Location Address
First Line	:	15299 BAGLEY RD STE 200
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44130-4823
Country	:	US
Telephone Number	:	440-663-0022
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	WARREN LAURITA
Credential	:
Telephone Number	:	216-831-4748

Provider Enumeration Date	:	11/25/2014
Last Update Date	:	11/25/2014

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