Provider Demographics
NPI:1003916479
Name:PURISIMA, MARY GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY GRACE
Middle Name:
Last Name:PURISIMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5105 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4203
Practice Address - Country:US
Practice Address - Phone:216-524-7377
Practice Address - Fax:440-975-4617
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-069057207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0207038Medicaid
PU0805544Medicare ID - Type Unspecified
OH0207038Medicaid