Basic Information
Provider Information | |||||||||
NPI: | 1396715868 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SWEENEY | ||||||||
FirstName: | WALTER | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 715 E WESTERN RESERVE RD | ||||||||
Address2: |   | ||||||||
City: | POLAND | ||||||||
State: | OH | ||||||||
PostalCode: | 445143358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3307263204 | ||||||||
FaxNumber: | 3307299316 | ||||||||
Practice Location | |||||||||
Address1: | 715 E WESTERN RESERVE RD | ||||||||
Address2: |   | ||||||||
City: | POLAND | ||||||||
State: | OH | ||||||||
PostalCode: | 445143358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3307263204 | ||||||||
FaxNumber: | 3307299316 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2006 | ||||||||
LastUpdateDate: | 09/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 34006342S | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 34.006342 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 2386458 | 05 | OH |   | MEDICAID | 4070652 | 01 | OH | MEDICARE PTAN | OTHER |