MEDICARE: DR. MARY MAILLOUX 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	207P00000X	Emergency Medicine Physician	ME62993	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23714	OTHER	FL	MEDICARE CORE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760485437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY MAILLOUX MD

Provider Business Mailing Address
First Line	:	4074 SW 101ST AVE
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33328-2205
Country	:	US
Telephone Number	:	954-476-5891
Fax Number	:

Provider Business Practice Location Address
First Line	:	3333 W COMMERCIAL BLVD
Second Line	:	STE 210
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33309-3407
Country	:	US
Telephone Number	:	877-751-1157
Fax Number	:	919-425-1596

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	02/15/2008

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