Provider Demographics
NPI:1245202472
Name:WILLOUGHBY ASC LLC
Entity Type:Organization
Organization Name:WILLOUGHBY ASC LLC
Other - Org Name:CDH ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:34940 RIDGE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4196
Mailing Address - Country:US
Mailing Address - Phone:440-953-8568
Mailing Address - Fax:440-953-4429
Practice Address - Street 1:34940 RIDGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4196
Practice Address - Country:US
Practice Address - Phone:440-953-8568
Practice Address - Fax:440-953-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0389AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2039645Medicaid
OH490003358Medicare PIN
OH3610871Medicare PIN
OH2039645Medicaid