Provider Demographics
NPI:1649221482
Name:JAY, MARY SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY SUSAN
Middle Name:
Last Name:JAY
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 1:8915 W CONNELL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3067
Mailing Address - Country:US
Mailing Address - Phone:414-266-2873
Mailing Address - Fax:414-337-7860
Practice Address - Street 1:8915 W CONNELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3067
Practice Address - Country:US
Practice Address - Phone:414-266-2873
Practice Address - Fax:414-337-7860
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI473152080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000030377MOtherHUMANA
WI1649221482Medicaid
WI34582200Medicaid
0024173601Medicare ID - Type Unspecified
000030377MOtherHUMANA