Basic Information
| Provider Information | |||||||||
| NPI: | 1023076031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMULLEN | ||||||||
| FirstName: | MARY JO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21755 BROOKPARK ROAD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407776300 | ||||||||
| FaxNumber: | 4407772330 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 WABASH AVE | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303441799 | ||||||||
| FaxNumber: | 3302538293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35040855 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0405823 | 05 | OH | MEDICAID |