Provider Demographics
NPI:1700873569
Name:TIBBETTS, MARY W (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5717
Mailing Address - Country:US
Mailing Address - Phone:207-626-1275
Mailing Address - Fax:207-621-1985
Practice Address - Street 1:6 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5717
Practice Address - Country:US
Practice Address - Phone:207-626-1275
Practice Address - Fax:207-626-1985
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME0171992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G88073Medicare UPIN