Provider Demographics
NPI:1023089653
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:MR
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 1:17747 CHILLICOTHE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-4739
Mailing Address - Country:US
Mailing Address - Phone:440-543-8855
Mailing Address - Fax:440-543-2470
Practice Address - Street 1:17747 CHILLICOTHE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-4739
Practice Address - Country:US
Practice Address - Phone:440-543-8855
Practice Address - Fax:440-543-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000028432OtherANTHEM
OH0139719Medicaid
OH0139719Medicaid
OH9265461Medicare PIN
OH1280450001Medicare NSC