Basic Information
| Provider Information | |||||||||
| NPI: | 1336183342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAULORICO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18697 BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408166246 | ||||||||
| FaxNumber: | 4408166263 | ||||||||
| Practice Location | |||||||||
| Address1: | 18697 BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408166246 | ||||||||
| FaxNumber: | 4408166263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN - 212067 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | CRNA.13154 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0987071 | 05 | OH | MEDICAID |