Basic Information
Provider Information | |||||||||
NPI: | 1104367820 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY PRIMARY CARE PRACTICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTER FOR OTHOPEDICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8792 | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049158792 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4403292800 | ||||||||
FaxNumber: | 4403292810 | ||||||||
Practice Location | |||||||||
Address1: | 224 W LORAIN ST | ||||||||
Address2: |   | ||||||||
City: | OBERLIN | ||||||||
State: | OH | ||||||||
PostalCode: | 440741096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4403292800 | ||||||||
FaxNumber: | 4403292810 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2017 | ||||||||
LastUpdateDate: | 06/30/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MEGARIAN | ||||||||
AuthorizedOfficialFirstName: | CLIFF | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | UHPS PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2168445500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 4252080042 | 01 | OH | MEDICARE NSC | OTHER |