Provider Demographics
NPI:1548206469
Name:LIPOVAN, MARY C (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:LIPOVAN
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 1:78 OVERLOOK PL
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-2930
Mailing Address - Country:US
Mailing Address - Phone:330-888-5920
Mailing Address - Fax:
Practice Address - Street 1:78 OVERLOOK PL
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-2930
Practice Address - Country:US
Practice Address - Phone:330-888-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-214507367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2007581Medicaid
OHLI8219986Medicare ID - Type Unspecified