Basic Information
| Provider Information | |||||||||
| NPI: | 1780079186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSH | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2002 OAKSHADE CT | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400142000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655860868 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST STE 303 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295552 | ||||||||
| FaxNumber: | 5026293132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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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 | 208000000X | 52306 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 52306 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.