Provider Demographics
NPI:1932260924
Name:POLAND CENTER FOR SLEEP, LTD.
Entity type:Organization
Organization Name:POLAND CENTER FOR SLEEP, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORTUNATO
Authorized Official - Suffix:
Authorized Official - Credentials:ESQUIRE
Authorized Official - Phone:330-757-3166
Mailing Address - Street 1:3296 STONES THROW AVE
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-4213
Mailing Address - Country:US
Mailing Address - Phone:330-757-3166
Mailing Address - Fax:330-757-8202
Practice Address - Street 1:3296 STONES THROW AVE
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-4213
Practice Address - Country:US
Practice Address - Phone:330-757-3166
Practice Address - Fax:330-757-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2597971Medicaid
OH000000381168OtherANTHEM
OH7204771OtherAETNA
OH80314OtherUNICARE
OH7204771OtherAETNA
OH2597971Medicaid