Provider Demographics
NPI:1053476242
Name:NEAL, MARY C (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:NEAL
Suffix:
Gender:F
Credentials:MD
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 7369
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-7369
Mailing Address - Country:US
Mailing Address - Phone:307-734-5999
Mailing Address - Fax:307-734-0345
Practice Address - Street 1:945 W BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-734-5999
Practice Address - Fax:307-734-0345
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6101A207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313180OtherBLUE CROSS BLUE SHIELD
WYW20066Medicare PIN
E02814Medicare UPIN
5440900001Medicare NSC
WY313180OtherBLUE CROSS BLUE SHIELD