Provider Demographics
NPI:1770574675
Name:REID, MARY ALICE M (MD)
Entity type:Individual
Prefix:
First Name:MARY ALICE
Middle Name:M
Last Name:REID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:MCGRAIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1627 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3817
Practice Address - Country:US
Practice Address - Phone:574-262-0313
Practice Address - Fax:574-262-8163
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044674208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200076800Medicaid
IN200076800Medicaid
IN236040095Medicare PIN