Provider Demographics
NPI:1891787271
Name:BLANK, MARY GRISWOLD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:GRISWOLD
Last Name:BLANK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6803 MAYFIELD RD
Mailing Address - Street 2:#305
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2271
Mailing Address - Country:US
Mailing Address - Phone:440-312-9000
Mailing Address - Fax:440-312-9001
Practice Address - Street 1:6803 MAYFIELD RD
Practice Address - Street 2:#305
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2271
Practice Address - Country:US
Practice Address - Phone:440-312-9000
Practice Address - Fax:440-312-9001
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2010-09-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35054147207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0692497Medicaid
OH0682473Medicare ID - Type Unspecified
OH0692497Medicaid