Basic Information
| Provider Information | |||||||||
| NPI: | 1174515274 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ABUZZAHAB | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JENNIFER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 LINCOLN DRIVE | ||||||||
| Address2: | CBC-2-REV/PE | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554361611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529925624 | ||||||||
| FaxNumber: | 9529926917 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 SMITH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512206624 | ||||||||
| FaxNumber: | 6512206064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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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 | 2080P0205X | 42796 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 887951600 | 05 | MN | MEDICAID |