Provider Demographics
NPI:1780682914
Name:MA, MARY H (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:MA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:1001 SILVER AVE SE
Practice Address - Street 2:PMG PEDIATRIC URGENT CARE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4904
Practice Address - Country:US
Practice Address - Phone:505-841-1819
Practice Address - Fax:505-841-1998
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2008-07-15
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Provider Licenses
StateLicense IDTaxonomies
NM9076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81908067Medicaid
NM81908067Medicaid
H76727Medicare UPIN