Basic Information
| Provider Information | |||||||||
| NPI: | 1124050497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST | ||||||||
| Address2: | FL 3 | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458563284 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109414028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 220224 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 208M00000X | 220224 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 220224 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02192372 | 05 | NY | MEDICAID | MK0027SX20 | 01 | NY | BCBS | OTHER |