Provider Demographics
NPI:1326230764
Name:MARYMOUNT PRIMARY CARE SERVICES, INC
Entity Type:Organization
Organization Name:MARYMOUNT PRIMARY CARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALCHANOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-543-8855
Mailing Address - Street 1:34501 AURORA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-3873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34501 AURORA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-3873
Practice Address - Country:US
Practice Address - Phone:440-914-0960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2088940Medicaid
OH000000564024OtherANTHEM
OH000000564024OtherANTHEM
OHCK0694Medicare PIN