Basic Information
| Provider Information | |||||||||
| NPI: | 1184170136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIGNATURE HEALTH INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38882 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440947875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408133341 | ||||||||
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| Practice Location | |||||||||
| Address1: | 53 S SAINT CLAIR ST | ||||||||
| Address2: | |||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440773418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405788200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2016 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | EGLESTON | ||||||||
| AuthorizedOfficialFirstName: | INDRANI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4405788200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 293D00000X | Y | Laboratories | Physiological Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0197471 | 05 | OH | MEDICAID |