Provider Demographics
NPI:1548244353
Name:WAIDE, MARK EDWARD (PAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:WAIDE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9150 MARKET SQUARE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4571
Mailing Address - Country:US
Mailing Address - Phone:330-626-2211
Mailing Address - Fax:330-626-2294
Practice Address - Street 1:9150 MARKET SQUARE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-4571
Practice Address - Country:US
Practice Address - Phone:330-626-2211
Practice Address - Fax:330-626-2294
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1032163363AM0700X
OH2570363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067558Medicaid
OHPA28342Medicare PIN
OHPA28341Medicare PIN
OH9289121Medicare PIN
OH9289122Medicare PIN