Provider Demographics
NPI:1609046267
Name:CLEVELAND PEDIATRICS,P.C.
Entity Type:Organization
Organization Name:CLEVELAND PEDIATRICS,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:OWNBY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CPMSM
Authorized Official - Phone:423-479-9733
Mailing Address - Street 1:435 25TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3838
Mailing Address - Country:US
Mailing Address - Phone:423-479-9733
Mailing Address - Fax:423-472-1890
Practice Address - Street 1:435 25TH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3838
Practice Address - Country:US
Practice Address - Phone:423-479-9733
Practice Address - Fax:423-472-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD16047208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3381759Medicaid