Basic Information
| Provider Information | |||||||||
| NPI: | 1174532071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITRI | ||||||||
| FirstName: | OSAMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80690 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447080690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308335530 | ||||||||
| FaxNumber: | 3308336085 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 SIXTH ST SW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303632180 | ||||||||
| FaxNumber: | 3303632179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-077131 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 95202 | 01 | OH | SUMMA HEALTH CARE | OTHER | 7860071 | 01 | OH | AETNA | OTHER | P00006997 | 01 | OH | RAILROAD MEDICARE | OTHER | 0401531 | 01 | OH | UNITED HEALTH CARE | OTHER | 2189297 | 05 | OH | MEDICAID | 279626 | 01 | OH | ANTHEM BLUE CROSS AND BLU | OTHER | 56-2352995 | 01 | OH | AULTCARE | OTHER |