Basic Information
| Provider Information | |||||||||
| NPI: | 1992710131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CEFALA | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3700 PARK EAST DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552921401 | ||||||||
| FaxNumber: | 8663968340 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 PARK EAST DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552921401 | ||||||||
| FaxNumber: | 8663968340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 05/27/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | RHL128733 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | G35876 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G358760 | 01 | CA | BCBS | OTHER | CA195365 | 01 | CA | NORTHERN CA | OTHER | WG35876B | 01 | CA | MEDICARE PTAN | OTHER | 1992710131 | 05 | CA | MEDICAID | CB249210 | 01 | CA | SOUTHERN CA | OTHER | P00610090 | 01 | CA | RR MEDICARE | OTHER |