Basic Information
| Provider Information | |||||||||
| NPI: | 1538160114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC PARTNERS OF CLEVELAND, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 567 | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440220567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164645160 | ||||||||
| FaxNumber: | 2164645982 | ||||||||
| Practice Location | |||||||||
| Address1: | 23250 CHAGRIN BLVD | ||||||||
| Address2: | SUITE #130 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165140100 | ||||||||
| FaxNumber: | 2165140171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WORTHINGTON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2165140100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 0165155 | 05 | OH | MEDICAID |