Basic Information
| Provider Information | |||||||||
| NPI: | 1487787727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN RESERVE CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GYPSY LN | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445041315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308845858 | ||||||||
| FaxNumber: | 3308845735 | ||||||||
| Practice Location | |||||||||
| Address1: | 3622 BELMONT AVE | ||||||||
| Address2: | SUITE 21 | ||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445051450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307593485 | ||||||||
| FaxNumber: | 3307593256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | LOWELL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM EXECUTIVE VP AND COO | ||||||||
| AuthorizedOfficialTelephone: | 3308845858 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 9736361 | 05 | OH | MEDICAID |