Provider Demographics
NPI:1316252240
Name:BULLIMORE, BENJAMIN D (NP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:D
Last Name:BULLIMORE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:STE 1000
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:419-261-9141
Mailing Address - Fax:
Practice Address - Street 1:1001 LAKESIDE AVE E
Practice Address - Street 2:STE 1000
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1158
Practice Address - Country:US
Practice Address - Phone:419-261-9141
Practice Address - Fax:216-420-9354
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA11632NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3144010Medicaid
OHBUNP37161Medicare PIN