Provider Demographics
NPI:1275626525
Name:KRALL, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KRALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9774
Mailing Address - Country:US
Mailing Address - Phone:815-842-3633
Mailing Address - Fax:815-844-6309
Practice Address - Street 1:2500 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9774
Practice Address - Country:US
Practice Address - Phone:815-842-3633
Practice Address - Fax:815-844-6309
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041127668/209001388363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S38087Medicare UPIN
ILK05745Medicare ID - Type UnspecifiedBLOOMINGTON GROUP #
IL238270Medicare ID - Type UnspecifiedPONTIAC INDIVIDUAL #
ILK35963Medicare ID - Type UnspecifiedINDIVIDUAL #
ILCA2182Medicare ID - Type UnspecifiedRR GROUP #
IL207991Medicare ID - Type UnspecifiedBLOOMINGTON GROUP #
IL833230Medicare ID - Type UnspecifiedGROUP #