Basic Information
| Provider Information | |||||||||
| NPI: | 1235173485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUGO | ||||||||
| FirstName: | MARYANN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | STE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 48 HILLS CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301782051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706848700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 57010 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | P00371698 | 01 | RAILROAD MEDICARE | OTHER | 204610 | 01 | BCBS | OTHER | 200647907 | 05 | MO | MEDICAID |