Basic Information
| Provider Information | |||||||||
| NPI: | 1932170990 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND REGIONAL MEDICAL CENTER LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLEVELAND REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844833 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844833 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 E CROCKETT ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773274029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815931811 | ||||||||
| FaxNumber: | 2814324370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTACCI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP, GROUP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8883739600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEVELAND REGIONAL MEDICAL CENTER LP | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 000108 | TX | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | HH0155 | 01 | BCBS | OTHER |