Provider Demographics
NPI:1124027438
Name:CHAMBERS, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CHAMBERS
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 1:1 S CREEK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-9472
Mailing Address - Country:US
Mailing Address - Phone:606-348-3365
Mailing Address - Fax:606-340-3413
Practice Address - Street 1:1 S CREEK DR STE 102
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-9472
Practice Address - Country:US
Practice Address - Phone:606-348-3365
Practice Address - Fax:606-340-3413
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053292A208000000X
KY33259208000000X
TN38747208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200302810Medicaid
IN200302810Medicaid