Provider Demographics
NPI:1538133483
Name:MCELLISTREM, MARY C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:MCELLISTREM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VAPHS; UNIVERSITY DRIVE C
Mailing Address - Street 2:MAILSTOP 130U
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15240
Mailing Address - Country:US
Mailing Address - Phone:412-688-6000
Mailing Address - Fax:
Practice Address - Street 1:3601 5TH AVE
Practice Address - Street 2:FALK CLINIC, SUITE 700
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3403
Practice Address - Country:US
Practice Address - Phone:412-648-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060961L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH08038Medicare UPIN
PA034223EXAMedicare ID - Type Unspecified