Basic Information
| Provider Information | |||||||||
| NPI: | 1972587806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERRIS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4845 E 14 MILE RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483106442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869775780 | ||||||||
| FaxNumber: | 5869770391 | ||||||||
| Practice Location | |||||||||
| Address1: | 4845 E 14 MILE RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483106442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869775780 | ||||||||
| FaxNumber: | 5869770391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 08/30/2013 | ||||||||
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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 | 207Q00000X | 5101007911 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1972587806 | 05 | MI | MEDICAID | 700H217350 | 01 | MI | BLUE SHIELD | OTHER | 121172 | 01 | MI | CARE-PREFERRED CHOICES | OTHER |