Basic Information
| Provider Information | |||||||||
| NPI: | 1093916116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZAHN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BRANAN ENNIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 713 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043965682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 820 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 713 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043965682 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 11/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 63859 | GA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | ME 107442 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002687800 | 05 | FL | MEDICAID | 643928689A | 05 | GA | MEDICAID | 148Y4 | 01 | FL | BLUE CROSS | OTHER |