Basic Information
| Provider Information | |||||||||
| NPI: | 1538167507 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TESTA | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 HASKINS RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434021600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193537069 | ||||||||
| FaxNumber: | 4193537076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1214 RIDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434022664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193528427 | ||||||||
| FaxNumber: | 4193522120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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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 | 207V00000X | 34-008063 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0704579 | 01 | OH | UHC | OTHER | 2424433 | 05 | OH | MEDICAID | 000000299764 | 01 | OH | ANTHEM | OTHER |