Provider Demographics
NPI:1619067543
Name:MCBRIDE, MARY JO
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6012
Mailing Address - Country:US
Mailing Address - Phone:631-581-5900
Mailing Address - Fax:
Practice Address - Street 1:519 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2619
Practice Address - Country:US
Practice Address - Phone:631-360-5900
Practice Address - Fax:631-360-9403
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5F0591Medicare ID - Type Unspecified
NYP50862Medicare UPIN