Provider Demographics
NPI:1275578197
Name:KRAVITZ, MARY H (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:KRAVITZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:HEHNEN
Other - Last Name:KRAVITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:4074 GANTZ RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4816
Mailing Address - Country:US
Mailing Address - Phone:614-917-1346
Mailing Address - Fax:614-259-0619
Practice Address - Street 1:4074 GANTZ RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-4816
Practice Address - Country:US
Practice Address - Phone:614-917-1346
Practice Address - Fax:614-259-0619
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.000647RX363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083217Medicaid