Provider Demographics
NPI:1194943860
Name:GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO
Entity type:Organization
Organization Name:GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-445-1035
Mailing Address - Street 1:408 NINTH STREET SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707
Mailing Address - Country:US
Mailing Address - Phone:330-445-1059
Mailing Address - Fax:330-454-1014
Practice Address - Street 1:408 NINTH STREET SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-4714
Practice Address - Country:US
Practice Address - Phone:330-445-1035
Practice Address - Fax:330-454-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA00436231H00000X
OHSP2281235Z00000X
OHSP8183235Z00000X
OHSP3189235Z00000X
261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH733018OtherBUCKEYE-MEDICAID HMO
OH733018OtherBUCKEYE HEALTH PLAN
OH0303042Medicaid
OH3303884Medicaid
OH366521Medicare ID - Type Unspecified