Provider Demographics
NPI:1215155015
Name:CLEVELAND BREAST CLINIC
Entity type:Organization
Organization Name:CLEVELAND BREAST CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHATILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-234-9338
Mailing Address - Street 1:18660 BAGLEY RD
Mailing Address - Street 2:STE. 305 BLDG. 2
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3483
Mailing Address - Country:US
Mailing Address - Phone:440-234-9338
Mailing Address - Fax:440-234-1448
Practice Address - Street 1:18660 BAGLEY RD
Practice Address - Street 2:STE. 305 BLDG. 2
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3483
Practice Address - Country:US
Practice Address - Phone:440-234-9338
Practice Address - Fax:440-234-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000006129197OtherBLUE CROSS
OH1500454OtherUMWA
OH1500454OtherUMWA