Provider Demographics
NPI:1780808790
Name:UNIVERSITY HOSPITALS MEDICAL GROUP, INC
Entity type:Organization
Organization Name:UNIVERSITY HOSPITALS MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MED STAFF SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-996-8671
Mailing Address - Street 1:PO BOX 772044
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2044
Mailing Address - Country:US
Mailing Address - Phone:440-732-3923
Mailing Address - Fax:
Practice Address - Street 1:3909 ORANGE PL STE 4100
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4480
Practice Address - Country:US
Practice Address - Phone:440-732-3923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9319232Medicare PIN