Basic Information
| Provider Information | |||||||||
| NPI: | 1063406874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELSH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4059 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074744059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738941263 | ||||||||
| FaxNumber: | 8889723703 | ||||||||
| Practice Location | |||||||||
| Address1: | 695 US HIGHWAY 46 | ||||||||
| Address2: | SUITE 400A | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070041592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738941263 | ||||||||
| FaxNumber: | 8889723703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/25/2006 | ||||||||
| NPIReactivationDate: | 04/05/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD054775L | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 25MA062000800 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 682200 | 05 | NJ | MEDICAID |