1659373538 NPI number — ROGER A MANSNERUS MD

Table of content: ROGER A MANSNERUS MD (NPI 1659373538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659373538 NPI number — ROGER A MANSNERUS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANSNERUS
Provider First Name:
ROGER
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1659373538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 COLUMBIA RD
Provider Second Line Business Mailing Address:
STE 150
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44145-1493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-250-5737
Provider Business Mailing Address Fax Number:
440-250-5738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 COLUMBIA RD
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-1493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-250-5737
Provider Business Practice Location Address Fax Number:
440-250-5738
Provider Enumeration Date:
08/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35044597 , 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: 0517131 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00360277 . This is a "RRCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00705952 . This is a "RAILROAD CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000501421 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341542312148 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 743124 . This is a "BCHP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 377322 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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