Provider Demographics
NPI:1679646541
Name:WOOSTER CLINIC LLC
Entity Type:Organization
Organization Name:WOOSTER CLINIC LLC
Other - Org Name:
Other - Org Type:
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 1:1740 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2204
Mailing Address - Country:US
Mailing Address - Phone:330-287-4500
Mailing Address - Fax:
Practice Address - Street 1:1740 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2204
Practice Address - Country:US
Practice Address - Phone:330-287-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-16
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042687332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1241260001Medicare NSC