Provider Demographics
NPI:1265669196
Name:UNIVERSITY HOSPITALS MEDICAL GROUP
Entity Type:Organization
Organization Name:UNIVERSITY HOSPITALS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCELROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-767-8717
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:MSC9152
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6299
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:5850 LANDERBROOK DR
Practice Address - Street 2:SUITE 306
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-6531
Practice Address - Country:US
Practice Address - Phone:216-844-3601
Practice Address - Fax:216-844-7117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152W00000X, 152WP0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2691903Medicaid
OHUN9364361Medicare PIN