MEDICARE: UNIVERSITY PRIMARY CARE PRACTICES, 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

General Provider Information

NPI Number	:	1902201056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY PRIMARY CARE PRACTICES, INC

Provider Business Mailing Address
First Line	:	PO BOX 8792
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-8792
Country	:	US
Telephone Number	:	216-743-8130
Fax Number	:	216-743-8131

Provider Business Practice Location Address
First Line	:	303 E ROYALTON RD
Second Line	:	STE 202
City	:	CLEVELAND
State	:	OH
Zip	:	44147-2591
Country	:	US
Telephone Number	:	216-743-8130
Fax Number	:	216-743-8131

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT MANAGER
Name	:	SHERYL JOHNSON
Credential	:
Telephone Number	:	216-692-1144

Provider Enumeration Date	:	10/31/2014
Last Update Date	:	11/10/2014

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