Healthcare Provider Details

I. General information

NPI: 1124339924
Provider Name (Legal Business Name): MARY-ELLEN MICK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MCDONALD ST
BLACKSBURG VA
24060-3420
US

IV. Provider business mailing address

105 MCDONALD ST
BLACKSBURG VA
24060-3420
US

V. Phone/Fax

Practice location:
  • Phone: 540-552-5545
  • Fax: 540-552-5568
Mailing address:
  • Phone: 540-552-5545
  • Fax: 540-552-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0102203412
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0116022638
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: