Provider Demographics
NPI:1497795629
Name:CONWAY, MARY G (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:CONWAY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:G
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4119
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4260
Practice Address - Country:US
Practice Address - Phone:708-331-3748
Practice Address - Fax:708-331-3605
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK25347Medicare PIN
ILK25346Medicare PIN