Provider Demographics
NPI:1487622528
Name:MARY P EVANS MD PLC
Entity type:Organization
Organization Name:MARY P EVANS MD PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:PALMQUIST
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-242-7077
Mailing Address - Street 1:PO BOX 6126
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-6126
Mailing Address - Country:US
Mailing Address - Phone:434-242-7077
Mailing Address - Fax:
Practice Address - Street 1:210 ELM AVE
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:VA
Practice Address - Zip Code:23093-6578
Practice Address - Country:US
Practice Address - Phone:434-242-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233405207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010155827Medicaid
VA010155827Medicaid
00W257M01Medicare PIN
VADD2220Medicare PIN
C09391Medicare PIN