Provider Demographics
NPI:1679511463
Name:MARYMOUNT HOSPITAL INC
Entity Type:Organization
Organization Name:MARYMOUNT HOSPITAL INC
Other - Org Name:MARYMOUNT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCT. OFFICER AND CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONGVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-636-7416
Mailing Address - Street 1:12300 MCCRACKEN ROAD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2914
Mailing Address - Country:US
Mailing Address - Phone:216-581-0500
Mailing Address - Fax:216-636-8088
Practice Address - Street 1:12300 MCCRACKEN ROAD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2914
Practice Address - Country:US
Practice Address - Phone:216-581-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1136273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2915171Medicaid
5000046OtherUNITED HEALTHCARE
100107OtherKAISER
6460670OtherAETNA
OH2915171Medicaid
OH=========134OtherMEDICAL MUTUAL OF OHIO