Healthcare Provider Details

I. General information

NPI: 1174742043
Provider Name (Legal Business Name): MARY CAROL LEBLANC BAILEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY BAILEY M.D.

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GRESHAM DRIVE 402 MEDICAL TOWER
NORFOLK VA
23507
US

IV. Provider business mailing address

400 GRESHAM DRIVE 402 MEDICAL TOWER
NORFOLK VA
23507
US

V. Phone/Fax

Practice location:
  • Phone: 757-627-7446
  • Fax: 757-624-1121
Mailing address:
  • Phone: 757-627-7446
  • Fax: 757-624-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number0101053031
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101053031
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101053031
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: