Provider Demographics
NPI:1720052772
Name:EDEN, DIANE HOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:HOLLY
Last Name:EDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:34900 CHARDON RD
Mailing Address - Street 2:STE 200
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9161
Mailing Address - Country:US
Mailing Address - Phone:440-951-5600
Mailing Address - Fax:
Practice Address - Street 1:35000 CHARDON RD
Practice Address - Street 2:SUITE #210
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9012
Practice Address - Country:US
Practice Address - Phone:440-951-5600
Practice Address - Fax:440-951-1293
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350544422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0711573Medicaid
OHD97938Medicare UPIN
OH0711573Medicaid