Basic Information
| Provider Information | |||||||||
| NPI: | 1316001480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUMO | ||||||||
| FirstName: | MARYANN | ||||||||
| MiddleName: | THERESE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCE | ||||||||
| OtherFirstName: | MARYANN | ||||||||
| OtherMiddleName: | THERESE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284248 | ||||||||
| FaxNumber: | 3178658314 | ||||||||
| Practice Location | |||||||||
| Address1: | 8733 W 400 N | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463609330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198790333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01036532A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.