Basic Information
| Provider Information | |||||||||
| NPI: | 1508885153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | MARY ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8500-8721 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737340188 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 WHITEHORSE MERCERVILLE RD | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086193835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095885081 | ||||||||
| FaxNumber: | 6095885086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
| 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 | 207RC0200X | MD050359L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 208M00000X | MD050359L | PA | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 101138584-02 | 01 | PA | AMERICHOICE FRANKFORD | OTHER | 34937 | 01 | PA | HEALTH PARTNERS BUCKS | OTHER | P00286205 | 01 | PA | RAILROAD MEDICARE | OTHER | 101138584-01 | 01 | PA | AMERICHOICE TORRESDALE | OTHER | 101138584-02 | 01 | PA | AMERICHOICE BUCKS | OTHER | 1011385840003 | 05 | PA | MEDICAID | 34935 | 01 | PA | HEALTH PARTNERS TORRES | OTHER | 1011385840002 | 05 | PA | MEDICAID | 1850152 | 01 | PA | UNITED HEALTHCARE | OTHER | 1128277 | 01 | PA | CIGNA | OTHER | 2334986000 | 01 | PA | KEYSTONE IBC | OTHER | 34936 | 01 | PA | HEALTH PARTNERS FRANK | OTHER | 1011385840001 | 05 | PA | MEDICAID | 30024403 | 01 | PA | KEYSTONE MERCY | OTHER | 1658650 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1658650 | 01 | PA | PERSONAL CHOICE | OTHER |