Healthcare Provider Details

I. General information

NPI: 1154391795
Provider Name (Legal Business Name): MARY LYNNE EVERETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HALL HIGHWAY
CRISFIELD MD
21817
US

IV. Provider business mailing address

201 HALL HIGHWAY
CRISFIELD MD
21817
US

V. Phone/Fax

Practice location:
  • Phone: 410-968-1200
  • Fax: 410-968-3005
Mailing address:
  • Phone: 410-968-1200
  • Fax: 410-968-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0059512
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number033079270
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: