MEDICARE: DR. MARY MAINLAND 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	246QL0900X	Laboratory Management Specialist/Technologist

General Provider Information

NPI Number	:	1659543494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY MAINLAND M.D.

Provider Business Mailing Address
First Line	:	8600 SHERIDAN RD STE 600
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-6515
Country	:	US
Telephone Number	:	262-605-6700
Fax Number	:	262-605-6715

Provider Business Practice Location Address
First Line	:	8600 SHERIDAN RD STE 600
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-6515
Country	:	US
Telephone Number	:	262-605-6700
Fax Number	:	262-605-6715

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

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	04/01/2008

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