Provider Demographics
NPI:1326147935
Name:AGNE, MARY C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:AGNE
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 1:2900 FRANK SCOTT PKWY W STE 980
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-234-9200
Mailing Address - Fax:618-234-3940
Practice Address - Street 1:2900 FRANK SCOTT PKWY W STE 980
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-234-9200
Practice Address - Fax:618-234-3940
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083251Medicaid
IL0821523294OtherBC/BS OF ILLINOIS
IL0821523294OtherBC/BS OF ILLINOIS
ILE58789Medicare UPIN