Provider Demographics
NPI:1316975303
Name:BEAN, MARY LAURA (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LAURA
Last Name:BEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6067
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-6067
Mailing Address - Country:US
Mailing Address - Phone:423-778-5445
Mailing Address - Fax:423-778-3157
Practice Address - Street 1:632 MORRISON SPRINGS RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-3416
Practice Address - Country:US
Practice Address - Phone:423-778-3329
Practice Address - Fax:423-778-3551
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN14633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3889895Medicare ID - Type Unspecified
TNA97000Medicare UPIN