Basic Information
| Provider Information | |||||||||
| NPI: | 1598757676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEARY | ||||||||
| FirstName: | CLEVELAND | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745233161 | ||||||||
| FaxNumber: | 5745233221 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745233161 | ||||||||
| FaxNumber: | 5745233221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01028349 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102669202 | 05 | MI | MEDICAID | 000000082226 | 01 | IN | ANTHEM | OTHER | 010029951 | 01 | IN | RAIL ROAD MEDICARE | OTHER | 100152390 | 05 | IN | MEDICAID |