Provider Demographics
NPI:1841697463
Name:RETINA ASSOCIATES OF CLEVELAND
Entity type:Organization
Organization Name:RETINA ASSOCIATES OF CLEVELAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-831-4748
Mailing Address - Street 1:3401 ENTERPRISE PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7340
Mailing Address - Country:US
Mailing Address - Phone:216-831-5700
Mailing Address - Fax:216-831-1959
Practice Address - Street 1:15299 BAGLEY RD STE 200
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-4823
Practice Address - Country:US
Practice Address - Phone:440-663-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA29311Medicare UPIN