Provider Demographics
NPI:1063497659
Name:BINGHAM, MARY COLLEEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:BINGHAM
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 665
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-0665
Mailing Address - Country:US
Mailing Address - Phone:217-342-7000
Mailing Address - Fax:217-342-7002
Practice Address - Street 1:1106 N MERCHANT ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2128
Practice Address - Country:US
Practice Address - Phone:217-342-7000
Practice Address - Fax:217-342-7002
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089053Medicaid
ILL50870Medicare ID - Type Unspecified
ILF86404Medicare UPIN