Provider Demographics
NPI:1699729657
Name:MORAN, MARY (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MORAN
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 1:16 FAHEY ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6029
Mailing Address - Country:US
Mailing Address - Phone:207-930-6772
Mailing Address - Fax:207-930-6709
Practice Address - Street 1:16 FAHEY ST STE 202
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6029
Practice Address - Country:US
Practice Address - Phone:207-930-6772
Practice Address - Fax:207-930-6709
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065620207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-065620Medicaid
ILK31861Medicare PIN
ILD16481Medicare UPIN
ILK31860Medicare PIN