Provider Demographics
NPI:1972521367
Name:MENZ, MARY N (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:N
Last Name:MENZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:N
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:151 W HIGH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1407
Practice Address - Country:US
Practice Address - Phone:815-705-1000
Practice Address - Fax:815-705-2709
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106941207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106941Medicaid
IL036.106941OtherLICENSE
ILK23512Medicare PIN
I47300Medicare UPIN
IL036106941Medicaid