Provider Demographics
NPI:1083670277
Name:SABOURIN, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SABOURIN
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 1:1310 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-1358
Mailing Address - Country:US
Mailing Address - Phone:608-253-1171
Mailing Address - Fax:608-253-8012
Practice Address - Street 1:1310 BROADWAY
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1358
Practice Address - Country:US
Practice Address - Phone:608-253-1171
Practice Address - Fax:608-253-8012
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32342-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083670277Medicaid
WIK400176850Medicare PIN
WIP01428797Medicare PIN
WI080178997Medicare PIN
WI004257155Medicare PIN
F19001Medicare UPIN
WI1000463OtherPHYSICIANS PLUS