Provider Demographics
NPI:1780637876
Name:CAMERON, MARY A (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:CAMERON
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 1:41600 RAYBURN DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-2080
Mailing Address - Country:US
Mailing Address - Phone:734-934-2579
Mailing Address - Fax:248-615-6600
Practice Address - Street 1:22821 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3230
Practice Address - Country:US
Practice Address - Phone:248-615-6600
Practice Address - Fax:248-615-6605
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301076620OtherPHYSICIAN LICENSE
MI16253OtherMCARE
MI2319198OtherUNITED HEALTH CARE
MI0M17170016Medicare ID - Type Unspecified
MI4542580Medicaid
MI137114OtherMERCY CARE CHOICES
MI383268406OtherEIN TAX ID#
MI7109522OtherAETNA
MICC3713OtherRR MEDICARE
MIP35120118Medicare PIN
MI4301076620OtherPHYSICIAN LICENSE
MI8544208OtherCIGNA
MIH88599Medicare UPIN