Provider Demographics
NPI:1326265000
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:MR
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 1:4400 ROCKSIDE RD
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2109
Mailing Address - Country:US
Mailing Address - Phone:216-573-1300
Mailing Address - Fax:216-503-5005
Practice Address - Street 1:4400 ROCKSIDE RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2109
Practice Address - Country:US
Practice Address - Phone:216-573-1300
Practice Address - Fax:216-503-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2698559Medicaid
OH000000564073OtherANTHEM
OHCB8190Medicare PIN
OH1280450002Medicare NSC
OH9301037Medicare PIN