Basic Information
| Provider Information | |||||||||
| NPI: | 1215280029 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EATING DISORDER MEDICAL SPECIALISTS OF CLEVELAND LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25550 CHAGRIN BLVD | ||||||||
| Address2: | 207 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650500 | ||||||||
| FaxNumber: | 2167650521 | ||||||||
| Practice Location | |||||||||
| Address1: | 25550 CHAGRIN BLVD | ||||||||
| Address2: | 207 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650500 | ||||||||
| FaxNumber: | 2167650521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | GIORDON | ||||||||
| AuthorizedOfficialFirstName: | MACHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3307232111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35083837 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.