Basic Information
| Provider Information | |||||||||
| NPI: | 1316914500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEATHERINGTON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5428 POLO WOODS CT | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450144778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138299731 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 STEFFEN AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452152338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135883623 | ||||||||
| FaxNumber: | 5135883649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 09/11/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-06-6966-W | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0160089 | 05 | OH | MEDICAID |