Provider Demographics
NPI:1710956693
Name:MANSARD MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MANSARD MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAHEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-452-8858
Mailing Address - Street 1:2600 TUSCARAWAS ST W
Mailing Address - Street 2:SUITE#500
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4644
Mailing Address - Country:US
Mailing Address - Phone:330-452-8858
Mailing Address - Fax:330-452-7797
Practice Address - Street 1:2600 TUSCARAWAS ST W
Practice Address - Street 2:SUITE#500
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4644
Practice Address - Country:US
Practice Address - Phone:330-452-8858
Practice Address - Fax:330-452-7797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0960974Medicaid
OH0960974Medicaid