Provider Demographics
NPI:1093196842
Name:LIVERGOOD, MARY C (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:LIVERGOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CHRISTINE
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3009 N BALLAS RD STE 351C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2324
Mailing Address - Country:US
Mailing Address - Phone:314-996-6800
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD STE 351C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2324
Practice Address - Country:US
Practice Address - Phone:314-996-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022010786207V00000X, 207VM0101X
WI70784207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1093196842Medicaid