Healthcare Provider Details

I. General information

NPI: 1295953065
Provider Name (Legal Business Name): MARY J BAILEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 GREAT TEAYS BLVD SUITE 6
SCOTT DEPOT WV
25560-9815
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD SUITE 6
SCOTT DEPOT WV
25560-9815
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-6999
  • Fax: 304-201-5019
Mailing address:
  • Phone: 304-757-6999
  • Fax: 304-201-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41101
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTP232
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22597
License Number StateWV

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier22597
Identifier TypeOTHER
Identifier StateWV
Identifier IssuerLICENSE
# 2
Identifier7100017680
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer
# 3
Identifier2748389
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 4
Identifier3810009259
Identifier TypeMEDICAID
Identifier StateWV
Identifier Issuer
# 5
IdentifierTP232
Identifier TypeOTHER
Identifier StateKY
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: