Provider Demographics
NPI:1639361074
Name:MARYMOUNT PRIMARY CARE SERVICES, INC
Entity Type:Organization
Organization Name:MARYMOUNT PRIMARY CARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALCHANOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-543-8855
Mailing Address - Street 1:12000 MCCRACKEN RD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2964
Mailing Address - Country:US
Mailing Address - Phone:216-663-7355
Mailing Address - Fax:216-663-7193
Practice Address - Street 1:12000 MCCRACKEN RD
Practice Address - Street 2:SUITE 450
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2964
Practice Address - Country:US
Practice Address - Phone:216-663-7355
Practice Address - Fax:216-663-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000564654OtherANTHEM
OH2087058Medicaid
OHCK0694Medicare PIN
OH9265462Medicare PIN