Provider Demographics
NPI:1861461634
Name:LE-BLISS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LE-BLISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15110 JOHN J DELANEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15110 JOHN J DELANEY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3544
Practice Address - Country:US
Practice Address - Phone:704-302-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32499208M00000X
NC9701030208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01030Medicaid
NC891059TMedicaid
NC1861461634Medicaid
NC891059TMedicaid
NC1861461634Medicaid
NCNCC757CMedicare PIN
NCG55989Medicare UPIN
NCNCC757BMedicare PIN
NCNCC757DMedicare PIN