Provider Demographics
NPI:1851370142
Name:MORTELL, MARY PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:MORTELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5000
Practice Address - Country:US
Practice Address - Phone:734-936-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI406545207RG0100X
MI4301406545207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2359882001OtherCIGNA
MI020022OtherMIDWEST HEALTH PLAN
MI2769932Medicaid
MI0H14989OtherBCBS GROUP
MI10004002OtherMEDICARE RAILROAD PTAN
MI0812110OtherBCBS INDIVIDUAL
MI4404019OtherAETNA
MI2769932Medicaid
MI020022OtherMIDWEST HEALTH PLAN
MI10004002OtherMEDICARE RAILROAD PTAN