Provider Demographics
NPI:1194794453
Name:DOUGHERTY, MARY C
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 N HERMITAGE RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3342
Mailing Address - Country:US
Mailing Address - Phone:724-981-5613
Mailing Address - Fax:724-981-4790
Practice Address - Street 1:449 N HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3342
Practice Address - Country:US
Practice Address - Phone:724-981-5613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050551L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA770854OtherHIGHMARK
PA3078526-001OtherCIGNA HEALTH CARE
PA000000114763OtherANTHEM
PA0014643360002Medicaid
PA7549166OtherAETNA HEALTH CARE
PA314524OtherUPMC HEALTH CARE
PA7549166OtherAETNA HEALTH CARE
PAF80824Medicare UPIN