Provider Demographics
NPI:1316001480
Name:FUMO, MARYANN THERESE (MD)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:THERESE
Last Name:FUMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYANN
Other - Middle Name:THERESE
Other - Last Name:LUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8865 W 400 N STE 130
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9596
Practice Address - Country:US
Practice Address - Phone:219-879-5143
Practice Address - Fax:219-872-2395
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036532A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G02117Medicare UPIN
IN185000Medicare ID - Type Unspecified