Provider Demographics
NPI:1275651622
Name:ALEXSANDRA M MAMONIS M D INC
Entity Type:Organization
Organization Name:ALEXSANDRA M MAMONIS M D INC
Other - Org Name:ALEXSANDRA M MAMONIS, MD, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:
Authorized Official - First Name:ALEXSANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAMONIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-896-9099
Mailing Address - Street 1:1700 BOETTLER RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685
Mailing Address - Country:US
Mailing Address - Phone:330-896-9099
Mailing Address - Fax:330-896-9199
Practice Address - Street 1:1700 BOETTLER RD
Practice Address - Street 2:SUITE 125
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685
Practice Address - Country:US
Practice Address - Phone:330-896-9099
Practice Address - Fax:330-896-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000168517OtherANTHEM BC/BS
OH2762050Medicaid
OHAL9370951Medicare PIN