Basic Information
| Provider Information | |||||||||
| NPI: | 1316066277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PRIMARY CARE PRACTICES INC | ||||||||
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| OtherOrganizationName: | SUBARBAN PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8792 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403494714 | ||||||||
| FaxNumber: | 4403492729 | ||||||||
| Practice Location | |||||||||
| Address1: | 34055 SOLON RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SOLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441392662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403494714 | ||||||||
| FaxNumber: | 4403492729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | RIDDLE | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2163836480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2282828 | 05 | OH | MEDICAID |