Healthcare Provider Details

I. General information

NPI: 1760913032
Provider Name (Legal Business Name): MARY MCKENNA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

120 OSLER UNIT 100
NAPERVILLE IL
60540-7429
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-5986
  • Fax:
Mailing address:
  • Phone: 630-428-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036.155532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: