MEDICARE: MARK EDWARD WAIDE PAC

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	1032163	CT
2	363AM0700X	Medical Physician Assistant	2570	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548244353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK EDWARD WAIDE PAC

Provider Business Mailing Address
First Line	:	9150 MARKET SQUARE DR
Second Line	:	SUITE 202
City	:	STREETSBORO
State	:	OH
Zip	:	44241-4571
Country	:	US
Telephone Number	:	330-626-2211
Fax Number	:	330-626-2294

Provider Business Practice Location Address
First Line	:	9150 MARKET SQUARE DR
Second Line	:	SUITE 202
City	:	STREETSBORO
State	:	OH
Zip	:	44241-4571
Country	:	US
Telephone Number	:	330-626-2211
Fax Number	:	330-626-2294

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

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	08/30/2012

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Directions to “ MARK EDWARD WAIDE PAC” Practice Location

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