Provider Demographics
NPI:1821360298
Name:MARY ANN CHAVEZ DO
Entity Type:Organization
Organization Name:MARY ANN CHAVEZ DO
Other - Org Name:SULLIVAN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-268-3901
Mailing Address - Street 1:1120 N SECTION ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-9200
Mailing Address - Country:US
Mailing Address - Phone:812-268-3901
Mailing Address - Fax:812-268-0674
Practice Address - Street 1:1120 N SECTION ST
Practice Address - Street 2:SULLIVAN MEDICAL CLINIC
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-9200
Practice Address - Country:US
Practice Address - Phone:812-268-3901
Practice Address - Fax:812-268-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002313A261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200343440Medicaid
G06963Medicare UPIN
IN200343440Medicaid