Provider Demographics
NPI:1720021546
Name:BLAU, JANICE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:MARIE
Last Name:BLAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33182 WREN HAVEN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-835-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004444B207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH942460636087OtherCARESOURCE
OH0740587Medicaid
OHBL0638456Medicare ID - Type Unspecified
OH942460636087OtherCARESOURCE