Healthcare Provider Details

I. General information

NPI: 1174731103
Provider Name (Legal Business Name): MARY T MCCARTHY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY T MCCARTHY APN

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST FEINBERG PAVILLION 4-508
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

1143 E FOX CHASE DR
ROUND LAKE BEACH IL
60073-4155
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-6421
  • Fax:
Mailing address:
  • Phone: 847-231-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0900X
TaxonomyEnterostomal Therapy Registered Nurse
License Number209003341
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: