Basic Information
| Provider Information | |||||||||
| NPI: | 1003903600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARY | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7550 LUCERNE DR | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | MIDDLEBURG HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402348833 | ||||||||
| FaxNumber: | 4402343313 | ||||||||
| Practice Location | |||||||||
| Address1: | 6087 RIDGE RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441294472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408847272 | ||||||||
| FaxNumber: | 4408847972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-05-0093 C | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 35-05-0093 C | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0552352 | 05 | OH | MEDICAID | 000000133316 | 01 | OH | ANTHEM | OTHER |