Basic Information
Provider Information | |||||||||
NPI: | 1740787068 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLEVELAND CLINIC FLORIDA (A NONPROFIT CORPORATION) | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLEVELAND CLINIC FLORIDA CORAL SPRINGS ASC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6801 BRECKSVILLE RD | ||||||||
Address2: | SUITE 20, RK2-7 | ||||||||
City: | INDEPENDENCE | ||||||||
State: | OH | ||||||||
PostalCode: | 44131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2166364969 | ||||||||
FaxNumber: | 2164421272 | ||||||||
Practice Location | |||||||||
Address1: | 5701 NORTH UNIVERSITY DRIVE | ||||||||
Address2: |   | ||||||||
City: | CORAL SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 33067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8774632010 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2018 | ||||||||
LastUpdateDate: | 03/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONGVILLE | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ACCT OFFICER & CONTROLLER,CCF | ||||||||
AuthorizedOfficialTelephone: | 2166367416 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.