Basic Information
| Provider Information | |||||||||
| NPI: | 1043470453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINIC REGIONAL PHYSICIANS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 77028 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441947028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164480111 | ||||||||
| FaxNumber: | 2164480617 | ||||||||
| Practice Location | |||||||||
| Address1: | 25875 SCIENCE PARK DR | ||||||||
| Address2: | AC1-2-108 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441227304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164480111 | ||||||||
| FaxNumber: | 2164480617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2164481200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEVELAND CLINIC FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0122X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DO1231 | 01 | OH | MEDICARE RR | OTHER | 2902381 | 05 | OH | MEDICAID |