Provider Demographics
NPI:1609884592
Name:ST JUDES MEDICAL CLINIC
Entity Type:Organization
Organization Name:ST JUDES MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:NELIDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ENRIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-271-1947
Mailing Address - Street 1:7211 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105
Mailing Address - Country:US
Mailing Address - Phone:216-271-1947
Mailing Address - Fax:216-271-0106
Practice Address - Street 1:7211 BROADWAY
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105
Practice Address - Country:US
Practice Address - Phone:216-271-1947
Practice Address - Fax:216-271-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033404208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0325866Medicaid
OH0325866Medicaid
OH9153031Medicare PIN