Basic Information
Provider Information | |||||||||
NPI: | 1467960575 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE CLEVELAND CLINIC FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLEVELAND CLINIC COLE EYE - AVON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6801 BRECKSVILLE RD | ||||||||
Address2: | SUITE 20, RK2-7 | ||||||||
City: | INDEPENDENCE | ||||||||
State: | OH | ||||||||
PostalCode: | 441315062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2166364969 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 33100 CLEVELAND CLINIC BLVD | ||||||||
Address2: |   | ||||||||
City: | AVON | ||||||||
State: | OH | ||||||||
PostalCode: | 440111390 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4406954010 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2018 | ||||||||
LastUpdateDate: | 01/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MEDVE | ||||||||
AuthorizedOfficialFirstName: | DANIEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2169733321 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   | OH | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   | 332H00000X |   |   | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
No ID Information.