1275651622 NPI number — ALEXSANDRA M MAMONIS M D INC

Table of content: (NPI 1275651622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275651622 NPI number — ALEXSANDRA M MAMONIS M D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALEXSANDRA M MAMONIS M D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ALEXSANDRA M MAMONIS, MD, INC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275651622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 BOETTLER RD
Provider Second Line Business Mailing Address:
SUITE 125
Provider Business Mailing Address City Name:
UNIONTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-896-9099
Provider Business Mailing Address Fax Number:
330-896-9199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 BOETTLER RD
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
UNIONTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-896-9099
Provider Business Practice Location Address Fax Number:
330-896-9199
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAMONIS
Authorized Official First Name:
ALEXSANDRA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT MD
Authorized Official Telephone Number:
330-896-9099

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35070377 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000168517 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2762050 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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