Basic Information
Provider Information | |||||||||
NPI: | 1366913808 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WINGSPAN CARE GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 22001 FAIRMOUNT BLVD | ||||||||
Address2: |   | ||||||||
City: | SHAKER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441184819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163208222 | ||||||||
FaxNumber: | 2163208733 | ||||||||
Practice Location | |||||||||
Address1: | 22001 FAIRMOUNT BLVD | ||||||||
Address2: |   | ||||||||
City: | SHAKER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441184819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163208222 | ||||||||
FaxNumber: | 2163208733 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/10/2018 | ||||||||
LastUpdateDate: | 08/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALL | ||||||||
AuthorizedOfficialFirstName: | LEIGH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 2163208222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.