Basic Information
| Provider Information | |||||||||
| NPI: | 1093794851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 MEDICAL LN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399392305 | ||||||||
| FaxNumber: | 2399390947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME47480 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0500X | ME47480 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZM0300X | ME47480 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology |
ID Information
| ID | Type | State | Issuer | Description | 374110900 | 05 | FL | MEDICAID |