Provider Demographics
NPI:1336340504
Name:UNIVERSITY PRIMARY CARE PRACTICES INC
Entity type:Organization
Organization Name:UNIVERSITY PRIMARY CARE PRACTICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO, EAST MARKET
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:DECARLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-285-2950
Mailing Address - Street 1:PO BOX 772928
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 WEST AVE STE 2
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278
Practice Address - Country:US
Practice Address - Phone:330-633-8341
Practice Address - Fax:330-633-8462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9275339Medicare PIN