Provider Demographics
NPI:1992958227
Name:MARYMOUNT CARE SERVICES LLC
Entity type:Organization
Organization Name:MARYMOUNT CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCHANOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-543-8855
Mailing Address - Street 1:17747 CHILLICOTHE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-4739
Mailing Address - Country:US
Mailing Address - Phone:440-543-8855
Mailing Address - Fax:
Practice Address - Street 1:17747 CHILLICOTHE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-4739
Practice Address - Country:US
Practice Address - Phone:440-543-8855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2907439Medicaid
OHD08861Medicare PIN
OH6243810001Medicare NSC
OH9379671Medicare PIN