Provider Demographics
NPI:1407077449
Name:CLEVELAND STATE UNIVERSITY SPEECH AND HEARING CLINIC
Entity Type:Organization
Organization Name:CLEVELAND STATE UNIVERSITY SPEECH AND HEARING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRPERSON, HEALTH SCIENCES DEPT.
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:216-687-2379
Mailing Address - Street 1:2121 EUCLID AVE # MC-429
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2214
Mailing Address - Country:US
Mailing Address - Phone:216-687-3804
Mailing Address - Fax:216-687-6993
Practice Address - Street 1:2121 EUCLID AVE # MC-429
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2214
Practice Address - Country:US
Practice Address - Phone:216-687-3804
Practice Address - Fax:216-687-6993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408286Medicaid
OH0408286Medicaid