Provider Demographics
NPI:1407879406
Name:SIGNATURE HEALTH, INC
Entity Type:Organization
Organization Name:SIGNATURE HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-953-9999
Mailing Address - Street 1:38879 MENTOR AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7992
Mailing Address - Country:US
Mailing Address - Phone:440-953-9999
Mailing Address - Fax:440-918-3839
Practice Address - Street 1:4200 PARK AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6887
Practice Address - Country:US
Practice Address - Phone:440-992-8552
Practice Address - Fax:440-992-8537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0467261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2325835Medicaid
OH2325835Medicaid