Provider Demographics
NPI:1528016433
Name:DJORDJEVICH, MARY T (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:DJORDJEVICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 N UNION ST
Mailing Address - Street 2:STE 104
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1369
Mailing Address - Country:US
Mailing Address - Phone:330-253-9145
Mailing Address - Fax:330-253-6222
Practice Address - Street 1:190 N UNION ST
Practice Address - Street 2:STE 104
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1369
Practice Address - Country:US
Practice Address - Phone:330-253-9145
Practice Address - Fax:330-253-6222
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-134256367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2080224OtherUNITED HEALTHCARE GROUP #
OH7091249Medicaid
OH0751511Medicaid
OH730544OtherBUCKEYE COMMUNITY HLTH PL
OH100153OtherEMPLYR KAISER GROUP #
OH000000125744OtherANTHEM BCBS INDV NUMBER
OH120747OtherKAISER PERMANENTE INDV #
OH2080224OtherUNITED HEALTHCARE GROUP #
OH120747OtherKAISER PERMANENTE INDV #
OH0751511Medicaid