=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821121120
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY C RELLAHAN DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 01/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2308 GREESIDE COURT
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-373-0981
-----------------------------------------------------
Fax | 904-373-0981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2308 GREENSIDE CT
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-373-0981
-----------------------------------------------------
Fax | 904-373-0981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | PO2236
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------