Basic Information
| Provider Information | |||||||||
| NPI: | 1700905304 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY PRIMARY CARE PRACTICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UHMP - PEDIATRICENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 74610 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441940693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836480 | ||||||||
| FaxNumber: | 2163836745 | ||||||||
| Practice Location | |||||||||
| Address1: | 5850 LANDERBROOK DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441244071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163830100 | ||||||||
| FaxNumber: | 2163836481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VALE | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2163836480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.