Provider Demographics
NPI:1841256013
Name:SIVIK, MARY TERESA (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:SIVIK
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 1:6701 ROCKSIDE RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2358
Mailing Address - Country:US
Mailing Address - Phone:216-524-4009
Mailing Address - Fax:216-524-7933
Practice Address - Street 1:6701 ROCKSIDE RD
Practice Address - Street 2:SUITE 330
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2358
Practice Address - Country:US
Practice Address - Phone:216-524-4009
Practice Address - Fax:216-524-7933
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069922207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT69922OtherSUMMACARE/APEX
OH000000139991OtherANTHEM
OH0288031Medicaid
OH000000139991OtherANTHEM
OHT69922OtherSUMMACARE/APEX
OH0804011Medicare PIN