Basic Information
| Provider Information | |||||||||
| NPI: | 1841238771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOB | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515461416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126443288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 122 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515461416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126443288 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 04/23/2012 | ||||||||
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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 | 207P00000X | 34122 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 34122 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.