Provider Demographics
NPI:1487884896
Name:TUDICO, MARINA GRITSIK (PA)
Entity type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:GRITSIK
Last Name:TUDICO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6780 MAYFIELD RD # HCS1-725
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2203
Mailing Address - Country:US
Mailing Address - Phone:440-312-6100
Mailing Address - Fax:440-312-0454
Practice Address - Street 1:6780 MAYFIELD RD / HCS1-725
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:440-312-6100
Practice Address - Fax:440-312-0454
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002279363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3V2764OtherHEALTHNET
CT200279OtherCONNECTICARE
CT200279OtherCONNECTICARE