Provider Demographics
NPI:1023090974
Name:CLEVELAND STATE UNIVERSITY HEALTH AND WELLNESS SERVICES
Entity type:Organization
Organization Name:CLEVELAND STATE UNIVERSITY HEALTH AND WELLNESS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:216-687-3649
Mailing Address - Street 1:2121 EUCLID AVE
Mailing Address - Street 2:UN 263
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2214
Mailing Address - Country:US
Mailing Address - Phone:216-687-3649
Mailing Address - Fax:216-687-9319
Practice Address - Street 1:2121 EUCLID AVE
Practice Address - Street 2:UN 263
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2214
Practice Address - Country:US
Practice Address - Phone:216-687-3649
Practice Address - Fax:216-687-9319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2329019Medicaid
OH36D0874476OtherCLIA
OH02-0251800OtherPHARM LICENSE #
OH02-0251800OtherPHARM LICENSE #