Basic Information
| Provider Information | |||||||||
| NPI: | 1154391795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERETT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 201 HALL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | CRISFIELD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109681200 | ||||||||
| FaxNumber: | 4109683005 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 HALL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | CRISFIELD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109681200 | ||||||||
| FaxNumber: | 4109683005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D0059512 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 033079270 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.