Provider Demographics
NPI:1063478998
Name:SANTIAGO, MARY ROSE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:SANTIAGO
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 1:1200 MILITARY ST S
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570-5003
Mailing Address - Country:US
Mailing Address - Phone:205-952-9824
Mailing Address - Fax:205-952-9815
Practice Address - Street 1:1200 MILITARY ST S
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570-5003
Practice Address - Country:US
Practice Address - Phone:205-952-9824
Practice Address - Fax:205-952-9815
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20519208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121585Medicaid
ALG61311Medicare UPIN
MS00121585Medicaid