Provider Demographics
NPI:1659357655
Name:ELINE, MARY JO (DO)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:ELINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY JO
Other - Middle Name:THERESA
Other - Last Name:WYSOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-812-4083
Mailing Address - Fax:717-812-2244
Practice Address - Street 1:35 MONUMENT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5074
Practice Address - Country:US
Practice Address - Phone:717-812-4083
Practice Address - Fax:717-812-2244
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0436032085R0202X
PAOS005976L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2502433OtherHIGHMARK BLUE SHIELD
PA1588746OtherGATEWAY-WMG
PA30075311OtherAMERIHEALTH MERCY-WMG
PA301200OtherUNISON-WMG
MD919374OtherCAREFIRST BCBS
PA102451961Medicaid
GA000869514CMedicaid
MD035832100Medicaid
PA751227OtherUPMC-WMG
MD919374OtherCAREFIRST BCBS
GAG70738Medicare UPIN
PA1588746OtherGATEWAY-WMG
GA30BDLZSMedicare ID - Type Unspecified