Provider Demographics
NPI:1992845531
Name:MARREN, MARY JANE (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:MARREN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 W 102ND ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2027
Mailing Address - Country:US
Mailing Address - Phone:773-636-3418
Mailing Address - Fax:
Practice Address - Street 1:2014 W 102ND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2027
Practice Address - Country:US
Practice Address - Phone:773-636-3418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056001061174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0071647296OtherBCBS
IL0061649364OtherBCBS