Provider Demographics
NPI:1598757676
Name:CLEARY, CLEVELAND C
Entity Type:Individual
Prefix:DR
First Name:CLEVELAND
Middle Name:C
Last Name:CLEARY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 EAST BLVD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2483
Mailing Address - Country:US
Mailing Address - Phone:574-523-3161
Mailing Address - Fax:574-523-3221
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3161
Practice Address - Fax:574-523-3221
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028349207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102669202Medicaid
IN000000082226OtherANTHEM
IN010029951OtherRAIL ROAD MEDICARE
IN100152390Medicaid
INE05339Medicare UPIN
IN100152390Medicaid