Basic Information
| Provider Information | |||||||||
| NPI: | 1104870120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUBURBAN NEURODIAGNOSTIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7500 OLD OAK BLVD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG HTS. | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441300000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407776300 | ||||||||
| FaxNumber: | 4407772330 | ||||||||
| Practice Location | |||||||||
| Address1: | 4180 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407776300 | ||||||||
| FaxNumber: | 4407772330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 01/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | MARS | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4408316085 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0755688 | 05 | OH | MEDICAID |