Provider Demographics
NPI:1548308802
Name:YOUR DIABETES ENDOCRINE NUTRITION GROUP, LLC
Entity type:Organization
Organization Name:YOUR DIABETES ENDOCRINE NUTRITION GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-266-5000
Mailing Address - Street 1:16101 SNOW RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44142-2817
Mailing Address - Country:US
Mailing Address - Phone:216-898-1633
Mailing Address - Fax:216-267-6526
Practice Address - Street 1:8300 TYLER BLVD
Practice Address - Street 2:STE 102
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4217
Practice Address - Country:US
Practice Address - Phone:440-266-5000
Practice Address - Fax:440-266-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9332441Medicare ID - Type Unspecified