Provider Demographics
NPI:1962497933
Name:MAHERN, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MAHERN
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 1:642 S WALKER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2158
Mailing Address - Country:US
Mailing Address - Phone:812-331-9160
Mailing Address - Fax:812-336-0277
Practice Address - Street 1:642 S WALKER ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2158
Practice Address - Country:US
Practice Address - Phone:812-331-9160
Practice Address - Fax:812-336-0277
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037667A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100184710Medicaid
E29044Medicare UPIN
INM21523004Medicare PIN
INM21523004Medicare PIN