Provider Demographics
NPI:1952464877
Name:CHENEY, MARYALICE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYALICE
Middle Name:
Last Name:CHENEY
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 1:1100 WALNUT ST
Mailing Address - Street 2:SUITE 702
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5563
Mailing Address - Country:US
Mailing Address - Phone:215-923-7176
Mailing Address - Fax:215-955-2404
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:SUITE 702
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5563
Practice Address - Country:US
Practice Address - Phone:215-923-7176
Practice Address - Fax:215-955-2404
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025382E208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1119530Medicaid
PAC34701Medicare UPIN