Provider Demographics
NPI:1265405237
Name:WALL, MARY JEAN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:WALL
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 1:108 W MAIN ST
Mailing Address - Street 2:PO BOX 305
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-1328
Mailing Address - Country:US
Mailing Address - Phone:419-483-4543
Mailing Address - Fax:419-483-0142
Practice Address - Street 1:1001 LAKESIDE AVE E STE 1200
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1172
Practice Address - Country:US
Practice Address - Phone:216-362-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059303W2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0783022Medicaid
OHP00286495OtherRAILROAD MC
OH000000339383OtherANTHEM
PA1018989380001Medicaid
PA1018989380002Medicaid
PA1018989380003Medicaid
WV3810008142Medicaid
PA1018989380002Medicaid
OHP00286495OtherRAILROAD MC
WV3810008142Medicaid
OH0783022Medicaid
PA117710W3RMedicare PIN