Healthcare Provider Details

I. General information

NPI: 1962561936
Provider Name (Legal Business Name): MARY ELLEN LOUISE VOMACKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 SOUTH FIRST STREET AFFILIATED COMMUNITY MEDICAL CENTERS
WILLMAR MN
56201
US

IV. Provider business mailing address

1604 SOUTH FIRST STREET AFFILIATED COMMUNITY MEDICAL CENTERS
WILLMAR MN
56201
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5079
  • Fax: 320-231-5067
Mailing address:
  • Phone: 320-231-5079
  • Fax: 320-231-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36746
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: