Basic Information
Provider Information | |||||||||
NPI: | 1669494274 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STELLA MARIS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1320 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441132333 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2167810550 | ||||||||
FaxNumber: | 2167817501 | ||||||||
Practice Location | |||||||||
Address1: | 1320 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441132333 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2167810550 | ||||||||
FaxNumber: | 2167817501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2006 | ||||||||
LastUpdateDate: | 07/19/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROCHE | ||||||||
AuthorizedOfficialFirstName: | MARGARET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2167810550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X |   | OH | Y |   | Hospital Units | Rehabilitation, Substance Use Disorder Unit |   |
ID Information
ID | Type | State | Issuer | Description | 1072 | 01 | OH | UPI | OTHER |