Provider Demographics
NPI:1356369581
Name:FREEMAN, MARY JO (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:FREEMAN
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:PO BOX 8004
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-8004
Mailing Address - Country:US
Mailing Address - Phone:715-847-2304
Mailing Address - Fax:
Practice Address - Street 1:425 PINE RIDGE BLVD
Practice Address - Street 2:SUITE 305B
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4123
Practice Address - Country:US
Practice Address - Phone:715-847-2036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20821207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30260300Medicaid
WIB84853Medicare UPIN
WI30260300Medicaid