Provider Demographics
NPI:1568481323
Name:MCCLURE, MARY L (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:MCCLURE
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:PO BOX 14806
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-0806
Mailing Address - Country:US
Mailing Address - Phone:614-261-3724
Mailing Address - Fax:614-447-9593
Practice Address - Street 1:7525 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5623
Practice Address - Country:US
Practice Address - Phone:330-758-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN101121367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0794949Medicaid
P00241028OtherMEDICARE RAILROAD
000000353839OtherANTHEM
MC8210943Medicare ID - Type Unspecified