Provider Demographics
NPI:1568657260
Name:PAVLO, JENNIFER ROSSER (MD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ROSSER
Last Name:PAVLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 PINE ST
Mailing Address - Street 2:STE 290
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7516
Mailing Address - Country:US
Mailing Address - Phone:317-805-4074
Mailing Address - Fax:
Practice Address - Street 1:525 E MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1619
Practice Address - Country:US
Practice Address - Phone:330-375-3167
Practice Address - Fax:330-375-7932
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA675832085R0202X
OH35.0990052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064634Medicaid
OH0064634Medicaid
OH204881619259OtherCARESOURCE
OHPO1095083OtherRAILROAD MEDICARE
OHH092440Medicare PIN
OH9589889OtherAETNA