Basic Information
| Provider Information | |||||||||
| NPI: | 1215992805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGUIRE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN,BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAUCK | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 700 BROADWAY AVE E | ||||||||
| Address2: | SUITE 39 | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172343091 | ||||||||
| FaxNumber: | 2172343094 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 BROADWAY AVE E | ||||||||
| Address2: | SUITE 39 | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172343091 | ||||||||
| FaxNumber: | 2172343094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 01/15/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209001207 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.