Provider Demographics
NPI:1740298116
Name:CORKERN, MARY S (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:CORKERN
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-288-4329
Mailing Address - Fax:601-288-3191
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-288-4329
Practice Address - Fax:601-288-3191
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16420208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120864Medicaid
110185644OtherRAILROAD MEDICARE
MS1559126OtherAMERICAN ADMIN GROUP
LA1490733Medicaid
MS00120864Medicaid
110001205Medicare ID - Type Unspecified