Basic Information
| Provider Information | |||||||||
| NPI: | 1053844498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | EVELYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRUGGEL | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6753 STATE RD | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441344517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408435544 | ||||||||
| FaxNumber: | 4408431633 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448052201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192891903 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2017 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | C.21600419-TRNE | OH | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.