Provider Demographics
NPI:1386683522
Name:MEIER, MARYJO (MD)
Entity Type:Individual
Prefix:
First Name:MARYJO
Middle Name:
Last Name:MEIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:611 E DOUGLAS RD STE 401
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1468
Practice Address - Country:US
Practice Address - Phone:574-335-6242
Practice Address - Fax:574-335-0758
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01054386A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102438797OtherANTHEM
IN200329260AMedicaid
H38924Medicare UPIN