Provider Demographics
NPI:1104008879
Name:OUTREACH PROFESSIONAL SERVICES INC
Entity Type:Organization
Organization Name:OUTREACH PROFESSIONAL SERVICES INC
Other - Org Name:CUYAHOGA PHYSICIAN NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-892-6406
Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:11201 SHAKER BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104
Practice Address - Country:US
Practice Address - Phone:216-721-6900
Practice Address - Fax:216-368-7905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0251856Medicaid