Provider Demographics
NPI:1417242587
Name:LALLY, MARY C (BMBCH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:LALLY
Suffix:
Gender:F
Credentials:BMBCH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:BARAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2325
Mailing Address - Country:US
Mailing Address - Phone:563-382-2911
Mailing Address - Fax:563-387-3102
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-382-2911
Practice Address - Fax:563-387-3102
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA42083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400112055Medicare PIN