MEDICARE: MRS. MARY LOUISE DALE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	50000225	OH

General Provider Information

NPI Number	:	1487601753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY LOUISE DALE PA-C

Provider Business Mailing Address
First Line	:	3694 STARRS CENTRE DR
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-9514
Country	:	US
Telephone Number	:	330-702-1310
Fax Number	:	330-702-1344

Provider Business Practice Location Address
First Line	:	3694 STARRS CENTRE DR
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-9514
Country	:	US
Telephone Number	:	330-702-1310
Fax Number	:	330-702-1344

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2006
Last Update Date	:	07/08/2007

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