Provider Demographics
NPI:1538106794
Name:CLEVELAND CLINIC CHILDREN'S HOSPITAL FOR REHABILITATION
Entity Type:Organization
Organization Name:CLEVELAND CLINIC CHILDREN'S HOSPITAL FOR REHABILITATION
Other - Org Name:CHILDREN'S HOSPITAL NEPHROLOGY & DIALYSIS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ACCT OFFICER AND CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONGVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-636-7416
Mailing Address - Street 1:6801 BRECKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-5032
Mailing Address - Country:US
Mailing Address - Phone:216-636-8364
Mailing Address - Fax:216-636-8445
Practice Address - Street 1:2801 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3815
Practice Address - Country:US
Practice Address - Phone:216-721-1494
Practice Address - Fax:216-721-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3779620Medicaid
OH3779620Medicaid