Provider Demographics
NPI:1659373538
Name:MANSNERUS, ROGER A (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:MANSNERUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 COLUMBIA RD
Mailing Address - Street 2:STE 150
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1493
Mailing Address - Country:US
Mailing Address - Phone:440-250-5737
Mailing Address - Fax:440-250-5738
Practice Address - Street 1:850 COLUMBIA RD
Practice Address - Street 2:STE 150
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1493
Practice Address - Country:US
Practice Address - Phone:440-250-5737
Practice Address - Fax:440-250-5738
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044597207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0517131Medicaid
OHP00360277OtherRRCARE
OHP00705952OtherRAILROAD CARE
OH000000501421OtherANTHEM BC/BS
OH341542312148OtherCARESOURCE
OH743124OtherBCHP
OH377322OtherWELLCARE
OH0535447Medicare PIN
OHP00360277OtherRRCARE
OH4053004Medicare PIN
OH0517131Medicaid