Organization
CLINIC PHYSICIAN SERVICES CO. LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TIM LONGVILLE (CHIEF ACCOUNTING OFFICER AND CONTRO)
(216) 636-7416
Entity
Organization
Contact information
Practice address
6780 MAYFIELD RD, MAYFIELD HTS, OH 44124-2203
(440) 312-4500
Mailing address
6801 BRECKSVILLE RD, RK1-19, INDEPENDENCE, OH 44131-5032
(216) 442-1840
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
—
—
208VP0014X
Interventional Pain Medicine Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2173615
—
OH
05
—
2173651
—
OH
05
—
2173660
—
OH
05
—
2175882
—
OH
05
—
2178272
—
OH
05
—
2178290
—
OH
05
—
2355099
—
OH
05
—
2475165
—
OH
05
—
2545811
—
OH
01
—
CG8024
RAILROAD MEDICARE
OH
Enumeration date
10/11/2005
Last updated
02/23/2022
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