Provider Demographics
NPI:1205829264
Name:PIZZA, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:PIZZA
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 1:2121 HUGHES DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3845
Mailing Address - Country:US
Mailing Address - Phone:419-291-2121
Mailing Address - Fax:419-479-6017
Practice Address - Street 1:2121 HUGHES DR
Practice Address - Street 2:SUITE 300
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3845
Practice Address - Country:US
Practice Address - Phone:419-291-2121
Practice Address - Fax:419-479-6017
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067177208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01873OtherPHC
MI3505802311OtherBCBS MI
OH000000141209OtherANTHEM
OH0105559OtherBCMH
OH0105559Medicaid
MI12-03671OtherUHC
MI4519541OtherAETNA
OH12-01242OtherUHC
MI000000270707OtherANTHEM
OH063626OtherAETNA
OH10725OtherHPM
OH01873OtherPHC
MI000000270707OtherANTHEM