Provider Demographics
NPI:1073889499
Name:TIERNEY, MARY G (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1227 WILLOW STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-4631
Mailing Address - Country:US
Mailing Address - Phone:717-723-9104
Mailing Address - Fax:717-349-9388
Practice Address - Street 1:2819 WILLOW STREET PIKE
Practice Address - Street 2:SUITE J
Practice Address - City:WILLOW STREET
Practice Address - State:PA
Practice Address - Zip Code:17584-1758
Practice Address - Country:US
Practice Address - Phone:717-723-9104
Practice Address - Fax:717-349-9388
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPAK000223171100000X
VA0101258266207Q00000X
MDD94419207Q00000X
PAMD456991207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171100000XOther Service ProvidersAcupuncturist
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA88-0786906OtherFAMILY MEDICINE