Provider Demographics
NPI:1922258417
Name:MARY WREN OB/GYN, PLLC
Entity Type:Organization
Organization Name:MARY WREN OB/GYN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-425-7300
Mailing Address - Street 1:628 HOSPITAL DR STE 2A
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2937
Mailing Address - Country:US
Mailing Address - Phone:870-425-7300
Mailing Address - Fax:870-425-7855
Practice Address - Street 1:628 HOSPITAL DR STE 3-E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2937
Practice Address - Country:US
Practice Address - Phone:870-425-7300
Practice Address - Fax:870-425-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7991207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARF83275Medicare UPIN