Basic Information
| Provider Information | |||||||||
| NPI: | 1912088501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY PRIMARY CARE PRACTICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | UHHS CHAGRIN HIGHLANDS URGENT CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8792 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168961800 | ||||||||
| FaxNumber: | 2168961801 | ||||||||
| Practice Location | |||||||||
| Address1: | 3909 ORANGE PL STE 2100 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441228400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168961800 | ||||||||
| FaxNumber: | 2168961801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 04/08/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIDDLE | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTIOR OF BILLING SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2163836480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 2204108 | 05 | OH | MEDICAID |