Basic Information
| Provider Information | |||||||||
| NPI: | 1225078181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2421 EDGEHILL RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441062407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322343 | ||||||||
| FaxNumber: | 4402573302 | ||||||||
| Practice Location | |||||||||
| Address1: | 23240 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650500 | ||||||||
| FaxNumber: | 2167650521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35061599 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0979419 | 05 | OH | MEDICAID |