Healthcare Provider Details

I. General information

NPI: 1114975414
Provider Name (Legal Business Name): MARY MORRISEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-3030
  • Fax: 217-698-3068
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-3068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: