Provider Demographics
NPI:1396001723
Name:MARY M. DICK, MD LLC
Entity Type:Organization
Organization Name:MARY M. DICK, MD LLC
Other - Org Name:MARY M. DICK, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-449-5800
Mailing Address - Street 1:2100 E BROADWAY
Mailing Address - Street 2:SUITE 325
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6082
Mailing Address - Country:US
Mailing Address - Phone:573-449-5800
Mailing Address - Fax:573-693-4190
Practice Address - Street 1:2100 E BROADWAY
Practice Address - Street 2:SUITE 325
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6082
Practice Address - Country:US
Practice Address - Phone:573-449-5800
Practice Address - Fax:573-693-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8178261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO309074OtherCOVENTRY HEALTH CARE PLAN
MO12382OtherANTHEM BLUE CROSS BLUE SHIELD
MO000004357Medicare UPIN
MO000004357Medicare PIN