Basic Information
| Provider Information | |||||||||
| NPI: | 1205829264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIZZA | ||||||||
| FirstName: | MARY ELLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 HUGHES DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912121 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 HUGHES DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912121 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| 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 | 208000000X | 35067177 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01873 | 01 | OH | PHC | OTHER | 3505802311 | 01 | MI | BCBS MI | OTHER | 000000141209 | 01 | OH | ANTHEM | OTHER | 0105559 | 01 | OH | BCMH | OTHER | 0105559 | 05 | OH | MEDICAID | 12-03671 | 01 | MI | UHC | OTHER | 4519541 | 01 | MI | AETNA | OTHER | 12-01242 | 01 | OH | UHC | OTHER | 000000270707 | 01 | MI | ANTHEM | OTHER | 063626 | 01 | OH | AETNA | OTHER | 10725 | 01 | OH | HPM | OTHER |