Provider Demographics
NPI:1578567343
Name:MCTIGUE, MARY KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:MCTIGUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1200 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4792
Mailing Address - Country:US
Mailing Address - Phone:812-339-6434
Mailing Address - Fax:812-331-0196
Practice Address - Street 1:1200 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4792
Practice Address - Country:US
Practice Address - Phone:812-339-6434
Practice Address - Fax:812-331-0196
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039092A207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100345180Medicaid
IN562570Medicare PIN
IN100345180Medicaid