Provider Demographics
NPI:1124194576
Name:MARY JO FORD MD INC
Entity Type:Organization
Organization Name:MARY JO FORD MD INC
Other - Org Name:PHOENIX PAIN MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-374-4100
Mailing Address - Street 1:555 PIER AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3800
Mailing Address - Country:US
Mailing Address - Phone:310-374-4100
Mailing Address - Fax:310-374-4111
Practice Address - Street 1:555 PIER AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3800
Practice Address - Country:US
Practice Address - Phone:310-374-4100
Practice Address - Fax:310-374-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73858174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE95002Medicare UPIN