Healthcare Provider Details

I. General information

NPI: 1659543494
Provider Name (Legal Business Name): MARY MAINLAND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 SHERIDAN RD STE 600
KENOSHA WI
53143-6515
US

IV. Provider business mailing address

8600 SHERIDAN RD STE 600
KENOSHA WI
53143-6515
US

V. Phone/Fax

Practice location:
  • Phone: 262-605-6700
  • Fax: 262-605-6715
Mailing address:
  • Phone: 262-605-6700
  • Fax: 262-605-6715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: