Basic Information
| Provider Information | |||||||||
| NPI: | 1578517637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANCAO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514705842 | ||||||||
| FaxNumber: | 2514705809 | ||||||||
| Practice Location | |||||||||
| Address1: | 1504 SPRINGHILL AVE | ||||||||
| Address2: | SUITE 1430 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366043207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514055147 | ||||||||
| FaxNumber: | 2514343852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/15/2008 | ||||||||
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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 | 208000000X | 17261 | AL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | 17261 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 92-10078 | 01 | AL | UNITED HEALTH CARE | OTHER | 00112081 | 05 | MS | MEDICAID | 51088377 | 01 | AL | BLUE CROSS | OTHER | 1115606 | 05 | LA | MEDICAID | 51505893 | 01 | AL | BLUE CROSS | OTHER |