Provider Demographics
NPI:1841238599
Name:MARY LISA GUNNING, MD
Entity Type:Organization
Organization Name:MARY LISA GUNNING, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNNING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-696-6655
Mailing Address - Street 1:21 TURNER LN
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4805
Mailing Address - Country:US
Mailing Address - Phone:610-696-6655
Mailing Address - Fax:610-696-8475
Practice Address - Street 1:21 TURNER LN
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4805
Practice Address - Country:US
Practice Address - Phone:610-696-6655
Practice Address - Fax:610-696-8475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041605-E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC33559Medicare UPIN
PA408029Medicare ID - Type Unspecified