Provider Demographics
NPI:1922193010
Name:CLEVELAND AVENUE PROFESSIONAL CENTER
Entity Type:Organization
Organization Name:CLEVELAND AVENUE PROFESSIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MILROY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-882-4343
Mailing Address - Street 1:200 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7515
Mailing Address - Country:US
Mailing Address - Phone:614-793-1980
Mailing Address - Fax:
Practice Address - Street 1:5910 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-6881
Practice Address - Country:US
Practice Address - Phone:614-882-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075146-S261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2465738Medicaid