Basic Information
| Provider Information | |||||||||
| NPI: | 1770540098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILLCREST DIAGNOSTIC INTERNAL MEDICINE SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21755 BROOKPARK ROAD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407776300 | ||||||||
| FaxNumber: | 4407772330 | ||||||||
| Practice Location | |||||||||
| Address1: | 6780 MAYFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407776300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PENSIERO | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4407776300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0708363 | 05 | OH | MEDICAID |