Provider Demographics
NPI:1841379690
Name:LYNN, MARY E (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:LYNN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:BLDG. 103, ROOM 1019
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-3380
Mailing Address - Fax:708-216-6148
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:BLDG. 103, ROOM 1019
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-3380
Practice Address - Fax:708-216-6148
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111813207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43521100Medicaid
I33088Medicare UPIN
021302120Medicare ID - Type Unspecified