Provider Demographics
NPI:1568458925
Name:THE CLEVELAND CLINIC FOUNDATION
Entity Type:Organization
Organization Name:THE CLEVELAND CLINIC FOUNDATION
Other - Org Name:CLEVELAND CLINIC PARK AVE WEST
Other - Org Type:Doing Business As
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 STE 20
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-5062
Mailing Address - Country:US
Mailing Address - Phone:216-636-4969
Mailing Address - Fax:216-442-1272
Practice Address - Street 1:484 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3118
Practice Address - Country:US
Practice Address - Phone:419-525-0330
Practice Address - Fax:419-994-2612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0899569Medicaid
OH0780800001Medicare NSC
OH0899569Medicaid
OHCH1408Medicare PIN