Basic Information
| Provider Information | |||||||||
| NPI: | 1629034285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OBEAR | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | EDITH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 860 MAIN RD | ||||||||
| Address2: | |||||||||
| City: | CORFU | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140369753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855996446 | ||||||||
| FaxNumber: | 5855993166 | ||||||||
| Practice Location | |||||||||
| Address1: | 860 MAIN RD | ||||||||
| Address2: | |||||||||
| City: | CORFU | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140369753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855996446 | ||||||||
| FaxNumber: | 5855993166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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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 | 207Q00000X | 205518 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QH0002X | 205518 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01909273 | 05 | NY | MEDICAID |