Provider Demographics
NPI:1629393723
Name:UNIVERSITY HOSPITALS MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:UNIVERSITY HOSPITALS MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCELROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-383-6756
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:OFFICE 1342
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6296
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:216-286-6296
Practice Address - Fax:216-286-6341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207T00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2691903Medicaid
OHUN9364361Medicare PIN