Provider Demographics
NPI:1538183066
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:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCHANOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:440-543-8855
Mailing Address - Street 1:275 SPRINGSIDE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4549
Mailing Address - Country:US
Mailing Address - Phone:330-670-5267
Mailing Address - Fax:
Practice Address - Street 1:17747 CHILLICOTHE RD
Practice Address - Street 2:SUITE 203
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:2006-07-27
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherTAX IDENTIFICATION NUMBER