Basic Information
| Provider Information | |||||||||
| NPI: | 1114104346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH-ST RITAS MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | DR. AMBALAVANAN M.D. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 73577 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965114 | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 W HIGH ST | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458013990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192279500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | RALSTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4199965119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | N/A | ||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | OH 35090880 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.