Provider Demographics
NPI:1295917318
Name:MARY ELAINE KROSSE, DPM
Entity type:Organization
Organization Name:MARY ELAINE KROSSE, DPM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:KROSSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-322-4220
Mailing Address - Street 1:860 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6542
Mailing Address - Country:US
Mailing Address - Phone:440-322-4220
Mailing Address - Fax:440-322-4713
Practice Address - Street 1:860 E BROAD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6542
Practice Address - Country:US
Practice Address - Phone:440-322-4220
Practice Address - Fax:440-322-4713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002297213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH42587891OtherMED. MUT. OF OHIO/SELECT
OH8333415578OtherMED. MUT. OF OHIO/GMCS
OH000000116728OtherANTHEM BC/BS
OH480006005OtherRAILROAD MEDICARE
OH0644379Medicaid
OHT80706Medicare UPIN
OH0644379Medicaid
OH42587891OtherMED. MUT. OF OHIO/SELECT