Provider Demographics
NPI:1467447516
Name:BOUGH, MARY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:BOUGH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5229 W VERNAL PIKE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-9661
Mailing Address - Country:US
Mailing Address - Phone:812-219-4927
Mailing Address - Fax:
Practice Address - Street 1:3901 HAGAN ST STE C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8516
Practice Address - Country:US
Practice Address - Phone:812-336-7552
Practice Address - Fax:812-336-7556
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001999A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200341440Medicaid
IN215570Medicare ID - Type UnspecifiedMEDICARE NUMBER
IN200341440Medicaid