Provider Demographics
NPI:1174532071
Name:MITRI, OSAMA
Entity type:Individual
Prefix:
First Name:OSAMA
Middle Name:
Last Name:MITRI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80690
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-0690
Mailing Address - Country:US
Mailing Address - Phone:330-833-5530
Mailing Address - Fax:330-833-6085
Practice Address - Street 1:2600 SIXTH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-363-2180
Practice Address - Fax:330-363-2179
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-077131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH95202OtherSUMMA HEALTH CARE
OH7860071OtherAETNA
OHP00006997OtherRAILROAD MEDICARE
OH0401531OtherUNITED HEALTH CARE
OH2189297Medicaid
OH279626OtherANTHEM BLUE CROSS AND BLU
OH56-2352995OtherAULTCARE
OHP00006997OtherRAILROAD MEDICARE
OH95202OtherSUMMA HEALTH CARE
OHWA9334001Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER