Provider Demographics
NPI:1609053107
Name:PHYSICIANS PROVIDER SERVICES,INC
Entity Type:Organization
Organization Name:PHYSICIANS PROVIDER SERVICES,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-921-5222
Mailing Address - Street 1:16603 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2203
Mailing Address - Country:US
Mailing Address - Phone:216-921-5222
Mailing Address - Fax:216-921-6421
Practice Address - Street 1:16603 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2203
Practice Address - Country:US
Practice Address - Phone:216-921-5222
Practice Address - Fax:216-921-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041190J305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2183622Medicaid
OH0414439Medicaid
9360691Medicare PIN