MEDICARE: MS. MARY PORATH M.A.

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	231H00000X	Audiologist	A-00289	OH

General Provider Information

NPI Number	:	1295859148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY PORATH M.A.

Provider Business Mailing Address
First Line	:	2244 HARCOURT DR
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44106-4622
Country	:	US
Telephone Number	:	732-754-2531
Fax Number	:

Provider Business Practice Location Address
First Line	:	2244 HARCOURT DR
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44106-4622
Country	:	US
Telephone Number	:	732-754-2531
Fax Number	:

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

Provider Enumeration Date	:	03/18/2007
Last Update Date	:	07/08/2007

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