Provider Demographics
NPI:1346496148
Name:SPENCER, MARY L (AA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:SPENCER
Suffix:
Gender:F
Credentials:AA
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:MARSH-SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18697 BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3417
Mailing Address - Country:US
Mailing Address - Phone:440-816-6246
Mailing Address - Fax:440-816-6263
Practice Address - Street 1:18697 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3417
Practice Address - Country:US
Practice Address - Phone:440-816-6246
Practice Address - Fax:440-816-6263
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000138367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2946370Medicaid