Provider Demographics
NPI:1649427634
Name:MARY ANN CHAVEZ DO PC
Entity type:Organization
Organization Name:MARY ANN CHAVEZ DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-268-3901
Mailing Address - Street 1:222 W BEECH ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-1462
Mailing Address - Country:US
Mailing Address - Phone:812-268-3901
Mailing Address - Fax:812-268-0674
Practice Address - Street 1:222 W BEECH ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-1462
Practice Address - Country:US
Practice Address - Phone:812-268-3901
Practice Address - Fax:812-268-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002313A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200343440Medicaid
IN200910590AMedicaid
ING06963Medicare UPIN
IN179820Medicare PIN