Provider Demographics
NPI:1902824188
Name:FONTANAROSA, MARY ANN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:FONTANAROSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 ELM RD NE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9393
Mailing Address - Country:US
Mailing Address - Phone:330-372-8800
Mailing Address - Fax:330-372-8999
Practice Address - Street 1:2600 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9393
Practice Address - Country:US
Practice Address - Phone:330-372-8800
Practice Address - Fax:330-372-8999
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000243195OtherANTHEM BC/BS OHIO
OH000028496OtherHIGHMARK BC/BS PA
OHQ004667OtherHOMETOWN
OH341341025036OtherCARESOURCE
OH400877OtherUNITED HEALTHCARE
OHJ50393OtherSUMMACARE
OH78933OtherHEALTH ASSURANCE
OH0631801Medicaid
OH110247884OtherRAILROAD MEDICARE