MEDICARE: DR. MARY LU MCNEILL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	38869	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1063551950	OTHER	GA	UPIN C19231

General Provider Information

NPI Number	:	1063551950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY LU MCNEILL MD

Provider Business Mailing Address
First Line	:	3605 BRASELTON HWY
Second Line	:	SUITE 101
City	:	DACULA
State	:	GA
Zip	:	30019-4666
Country	:	US
Telephone Number	:	678-804-7430
Fax Number	:	678-804-7418

Provider Business Practice Location Address
First Line	:	3605 BRASELTON HWY
Second Line	:	SUITE 101
City	:	DACULA
State	:	GA
Zip	:	30019-4666
Country	:	US
Telephone Number	:	678-804-7430
Fax Number	:	678-804-7418

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	05/16/2013

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