Basic Information
| Provider Information | |||||||||
| NPI: | 1114005659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECIALTY HOSPITAL OF CLEVELAND, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINDRED HOSPITAL - CLEVELAND - GATEWAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 S 4TH ST | ||||||||
| Address2: | K-LIVE 5 REIMBURSEMENT | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 5025964134 | ||||||||
| Practice Location | |||||||||
| Address1: | 2351 E 22ND ST | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165922830 | ||||||||
| FaxNumber: | 2165922831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967563 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 1434 | OH | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000000309904 | 01 | OH | BLUE CROSS | OTHER | 2420606 | 05 | OH | MEDICAID |