Provider Demographics
NPI:1265437180
Name:BEATTY, MARY ELLEN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:BEATTY
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 1:13020 N TELECOM PARKWAY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6124
Practice Address - Street 1:13020 N TELECOM PARKWAY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6124
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME394342082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4240438OtherAETNA
FL1732948OtherCIGNA
FL240001743OtherMEDICARE RAILROAD
FL30884OtherBC/BS
FL042695400Medicaid
FL209671OtherAVMED
FL209671OtherAVMED