Provider Demographics
NPI:1942271259
Name:ANTHONY, MARY E (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:ANTHONY
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 1:17840 BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3401
Mailing Address - Country:US
Mailing Address - Phone:440-665-3064
Mailing Address - Fax:
Practice Address - Street 1:17840 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3401
Practice Address - Country:US
Practice Address - Phone:440-665-3054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007507A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2333193Medicaid
OH4082594Medicare PIN
OH4082593Medicare PIN
OH2333193Medicaid
OH4082592Medicare PIN