Provider Demographics
NPI:1366481053
Name:VARGHESE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VARGHESE
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 1:16455 STATESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16455 STATESVILLE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7135
Practice Address - Country:US
Practice Address - Phone:704-302-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20724207R00000X
NC200000153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPO1241916OtherRAILROAD MEDICARE
SC207243Medicaid
G09745Medicare UPIN
SCAA87935019Medicare PIN
SCAA87935096Medicare PIN
SC207243Medicaid