Provider Demographics
NPI:1104809888
Name:FACCIOLO, MARY ANNE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:FACCIOLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8110 MAPLE LAWN BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2694
Mailing Address - Country:US
Mailing Address - Phone:301-340-8339
Mailing Address - Fax:301-340-9027
Practice Address - Street 1:7801 YORK RD
Practice Address - Street 2:STE 133
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7446
Practice Address - Country:US
Practice Address - Phone:410-339-7447
Practice Address - Fax:410-339-3684
Is Sole Proprietor?:No
Enumeration Date:2005-11-27
Last Update Date:2023-10-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0029319207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD994LMedicare UPIN
MD994LM414Medicare PIN