Basic Information
| Provider Information | |||||||||
| NPI: | 1669516837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGINN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MARGARET | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAGINN | ||||||||
| OtherFirstName: | PEG | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | SLP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7811 WATERSEDGE CV | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047847 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3320 N CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468051918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 235Z00000X | 22000930A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 000000080879 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER |