Basic Information
| Provider Information | |||||||||
| NPI: | 1366947913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANKS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | OSU WEXNER MEDICAL CENTER/NATIONWIDE CHILDREN'S MED-PED | ||||||||
| Address2: | 1405 S. HIGH ST. | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143559000 | ||||||||
| FaxNumber: | 6143559010 | ||||||||
| Practice Location | |||||||||
| Address1: | OSUMC/NATIONWIDE CHILDREN'S MED-PED RESIDENCY PROGRAM | ||||||||
| Address2: | 1405 S. HIGH ST | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143559000 | ||||||||
| FaxNumber: | 6143559010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2018 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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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 | 207R00000X | 57.246189 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 57.246189 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 57.246189 | 01 | OH | STATE MEDICAL BOARD OF OHIO | OTHER |