Provider Demographics
NPI:1316984057
Name:HOFFMAN, MARY R (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:HOFFMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N 4TH ST
Mailing Address - Street 2:PO BOX 19670
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5238
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-747-1351
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-747-1351
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110636208M00000X
IL036-110636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316984057Medicaid
IL036110636Medicaid
I21882Medicare UPIN
ILK31797Medicare PIN
I21882Medicare UPIN
IL256510Medicare PIN
ILP00478878OtherRR MDCR
ILIL1682039Medicare PIN