Provider Demographics
NPI:1265405062
Name:MCADOO, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCADOO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 PINE CONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-8638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:QUEEN CITY REGIONAL MEDICAL CLINIC
Practice Address - Street 2:1420 N. 10TH STREET
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1532
Practice Address - Country:US
Practice Address - Phone:605-642-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4916208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6701480Medicaid
SD6701480Medicaid
SDG73496Medicare UPIN