Provider Demographics
NPI:1558322735
Name:FITCH, MARY T (PAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:FITCH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7255 OLD OAK BLVD
Mailing Address - Street 2:STE C108
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7255 OLD OAK BLVD
Practice Address - Street 2:STE C108
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3329
Practice Address - Country:US
Practice Address - Phone:440-816-2786
Practice Address - Fax:440-816-5454
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1687363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPAPA18051Medicare ID - Type Unspecified