Basic Information
| Provider Information | |||||||||
| NPI: | 1871931147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDDY | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12539 ST CROIX PL | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231143265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036085907 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E. MEDICAL CENTER DRIVE | ||||||||
| Address2: | B1-380 TC | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347637919 | ||||||||
| FaxNumber: | 7347639298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2013 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301102521 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 0101261941 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.