Provider Demographics
NPI:1518003284
Name:MARYMOUNT SPECIAL SERVICES
Entity Type:Organization
Organization Name:MARYMOUNT SPECIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD OF CARDIOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:WAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-475-5370
Mailing Address - Street 1:PO BOX 72083
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0002
Mailing Address - Country:US
Mailing Address - Phone:440-879-0081
Mailing Address - Fax:440-879-0084
Practice Address - Street 1:12300 MCCRACKEN RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2914
Practice Address - Country:US
Practice Address - Phone:216-587-8867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0509702Medicaid
OH=========OtherANTHEM
OH0509702Medicaid
OH0509702Medicaid