MEDICARE: DR. MARY R HANNAMAN M.D.

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	208D00000X	General Practice Physician	G7318	TX
2	208100000X	Physical Medicine & Rehabilitation Physician	G7318	TX

General Provider Information

NPI Number	:	1255450797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY R HANNAMAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 16533
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76162-0533
Country	:	US
Telephone Number	:	817-269-6872
Fax Number	:	817-393-1798

Provider Business Practice Location Address
First Line	:	5012 TRINITY LANDING DR W
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3736
Country	:	US
Telephone Number	:	817-269-6872
Fax Number	:	817-393-1798

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	08/23/2019

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