Provider Demographics
NPI:1598838112
Name:HANNA, MARY M (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:HANNA
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 1:1812 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3910
Mailing Address - Country:US
Mailing Address - Phone:718-761-0124
Mailing Address - Fax:718-761-1166
Practice Address - Street 1:1812 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3910
Practice Address - Country:US
Practice Address - Phone:718-761-0124
Practice Address - Fax:718-761-1166
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108377208000000X
NJ34907208000000X
CAA23936208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00191777Medicaid
NY00191777Medicaid
B87368Medicare UPIN