Basic Information
Provider Information | |||||||||
NPI: | 1134181845 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EUCLID CARDIOLOGY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7500 OLD OAK BLVD | ||||||||
Address2: |   | ||||||||
City: | MIDDLEBURG HTS. | ||||||||
State: | OH | ||||||||
PostalCode: | 441300000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4407776300 | ||||||||
FaxNumber: | 4407772330 | ||||||||
Practice Location | |||||||||
Address1: | 18901 LAKESHORE BLVD | ||||||||
Address2: |   | ||||||||
City: | EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 44119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4409425400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 01/27/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOTTI | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4409424374 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 0722052 | 05 | OH |   | MEDICAID |