Provider Demographics
NPI:1437147402
Name:BAUER, MARY THERESA (PAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
Last Name:BAUER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6701 ROCKSIDE RD
Mailing Address - Street 2:#260
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2358
Mailing Address - Country:US
Mailing Address - Phone:216-369-2525
Mailing Address - Fax:216-369-2531
Practice Address - Street 1:6701 ROCKSIDE RD
Practice Address - Street 2:#260
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2358
Practice Address - Country:US
Practice Address - Phone:216-369-2525
Practice Address - Fax:216-369-2531
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000493627OtherANTHEM
OHPA18443Medicare PIN
OH000000493627OtherANTHEM