Provider Demographics
NPI:1376639294
Name:MERDIAN-BENDER, MARY G
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:G
Last Name:MERDIAN-BENDER
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 1:124 COTTONWOOD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 TREMONT STREET
Practice Address - Street 2:
Practice Address - City:HOPEDALE
Practice Address - State:IL
Practice Address - Zip Code:61747
Practice Address - Country:US
Practice Address - Phone:309-449-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered