Provider Demographics
NPI:1881008738
Name:BOREN, MARY MAUREEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAUREEN
Last Name:BOREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:LONGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8375 S HOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8344
Mailing Address - Country:US
Mailing Address - Phone:414-764-5726
Mailing Address - Fax:414-764-6954
Practice Address - Street 1:8375 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8344
Practice Address - Country:US
Practice Address - Phone:414-764-5726
Practice Address - Fax:414-764-6954
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71610-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1881008738Medicaid