Provider Demographics
NPI:1891761912
Name:GARRISON, MARY P (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:GARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 LAKE CONCORD RD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3057
Practice Address - Country:US
Practice Address - Phone:704-403-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500099208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139MJOtherBCBS
NC561706219OtherPRACTICE TAX ID
NC2551501OtherUHC
NC5900975Medicaid
NC7406744OtherAETNA
NCE4512OtherMEDCOST
NCI30263Medicare UPIN