Provider Demographics
NPI:1811218548
Name:MCILWAIN, MARY JAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY JAYNE
Middle Name:
Last Name:MCILWAIN
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 1:133 E FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2222
Mailing Address - Country:US
Mailing Address - Phone:717-394-9821
Mailing Address - Fax:717-394-0175
Practice Address - Street 1:133 E FREDERICK ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2222
Practice Address - Country:US
Practice Address - Phone:717-394-9821
Practice Address - Fax:717-394-0175
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC165309390200000X
PAMD451688207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA353853EHYMedicare PIN