Provider Demographics
NPI:1255363172
Name:MCMANMON, MARY PATRICIA (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:MCMANMON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2714 S 11TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4761
Mailing Address - Country:US
Mailing Address - Phone:269-683-1700
Mailing Address - Fax:269-683-7038
Practice Address - Street 1:148 W HIVELY AVE STE 1
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-2191
Practice Address - Country:US
Practice Address - Phone:574-293-0052
Practice Address - Fax:574-343-1390
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079052207Q00000X
IN01055036A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE78855Medicare UPIN