Provider Demographics
NPI:1104810860
Name:LEARY, MARY ANN (DO)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:LEARY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 W ELM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2007
Mailing Address - Country:US
Mailing Address - Phone:610-567-6967
Mailing Address - Fax:610-567-6955
Practice Address - Street 1:3301 RIDGE PIKE
Practice Address - Street 2:
Practice Address - City:EAGLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403-1411
Practice Address - Country:US
Practice Address - Phone:610-539-9100
Practice Address - Fax:610-539-6570
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS008302L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015040010005Medicaid
PA610285JQFMedicare PIN
PAF98217Medicare UPIN