Provider Demographics
NPI:1164518569
Name:HEATH, MARY DELPHINE (MD, MPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DELPHINE
Last Name:HEATH
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SEWANEE
Mailing Address - State:TN
Mailing Address - Zip Code:37375-2336
Mailing Address - Country:US
Mailing Address - Phone:931-598-9761
Mailing Address - Fax:931-598-5038
Practice Address - Street 1:1318 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SEWANEE
Practice Address - State:TN
Practice Address - Zip Code:37375-2336
Practice Address - Country:US
Practice Address - Phone:931-598-9761
Practice Address - Fax:931-598-5038
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1871997841OtherGROUP NPI (SEWANEE PEDIATRICS)
TN1515467Medicaid