Provider Demographics
NPI:1588764864
Name:CITY OF ELYRIA
Entity type:Organization
Organization Name:CITY OF ELYRIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-323-7595
Mailing Address - Street 1:202 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5325
Mailing Address - Country:US
Mailing Address - Phone:440-323-7595
Mailing Address - Fax:440-284-1558
Practice Address - Street 1:202 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5325
Practice Address - Country:US
Practice Address - Phone:440-323-7595
Practice Address - Fax:440-284-1558
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF ELYRIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020261600251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0299369Medicaid
OH9224621Medicare PIN