Basic Information
| Provider Information | |||||||||
| NPI: | 1447238282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLANCE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64916 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816469 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 MEDICAL PKWY | ||||||||
| Address2: | ACUTE CARE PAVILION | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811000 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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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 | D38328 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | D38328 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 6263782 | 01 | AETNA HMO | OTHER | S3990059 | 01 | BCBS DC | OTHER | 53072411 | 01 | BCBS MARYLAND | OTHER | 142441600 | 05 | MD | MEDICAID | 5926262 | 01 | AETNA PPO | OTHER |