Provider Demographics
NPI:1750441853
Name:THEROUX, MARY C (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:THEROUX
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 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:A.I. DUPONT HOSPITAL FOR CHILDREN
Practice Address - Street 2:1600 ROCKLAND ROAD
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003285207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001217513Medicaid
SCQ03285Medicaid
NY1437865Medicaid
VA5747473Medicaid
NC7613677Medicaid
NJ5032407Medicaid
MD7742614Medicaid
MD7742614Medicaid
000831T34Medicare PIN