Provider Demographics
NPI:1295953065
Name:BAILEY, MARY J (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9815
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:97 GREAT TEAYS BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9815
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-201-5019
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41101208000000X
KYTP232208000000X
WV22597208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV22597OtherLICENSE
KY7100017680Medicaid
OH2748389Medicaid
WV3810009259Medicaid
KYTP232OtherLICENSE
OH2748389Medicaid
WVWV4649B249Medicare PIN
WVWV4649AMedicare PIN
KY7100017680Medicaid
WVWV4649BMedicare PIN
WVWV4649CMedicare PIN
KY3403647Medicare PIN