Provider Demographics
NPI:1821354697
Name:BELZ, MARY MARTHA (STNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARTHA
Last Name:BELZ
Suffix:
Gender:F
Credentials:STNA
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 8681
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43058-8681
Mailing Address - Country:US
Mailing Address - Phone:740-258-8897
Mailing Address - Fax:
Practice Address - Street 1:4546 MARTINSBURG RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-9644
Practice Address - Country:US
Practice Address - Phone:740-366-5019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2688444Medicaid