Provider Demographics
NPI:1356650493
Name:OUTREACH PROFESSIONAL SERVICE, INC.
Entity Type:Organization
Organization Name:OUTREACH PROFESSIONAL SERVICE, 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 1:2322 E 22ND ST
Practice Address - Street 2:SUITE 310
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3176
Practice Address - Country:US
Practice Address - Phone:216-363-2732
Practice Address - Fax:216-363-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0251856Medicaid
OH9322324Medicare PIN