MEDICARE: MARY PURNELL MADDOCK 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	207L00000X	Anesthesiology Physician	D5269	TX

General Provider Information

NPI Number	:	1255320149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY PURNELL MADDOCK MD

Provider Business Mailing Address
First Line	:	804 SCOTT NIXON MEMORIAL DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30907-2464
Country	:	US
Telephone Number	:	713-659-3284
Fax Number	:

Provider Business Practice Location Address
First Line	:	1315 ST JOSEPH PKWY
Second Line	:	#302
City	:	HOUSTON
State	:	TX
Zip	:	77002-8233
Country	:	US
Telephone Number	:	713-659-3284
Fax Number	:

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

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	05/05/2010

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