Basic Information
| Provider Information | |||||||||
| NPI: | 1770695389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OSTERLUND | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18667 | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410180667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595723617 | ||||||||
| FaxNumber: | 8595722326 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595723617 | ||||||||
| FaxNumber: | 8595722326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/03/2015 | ||||||||
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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 | 207P00000X | 35-073339 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 42428 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200541570 | 05 | IN | MEDICAID | 2202440 | 05 | OH | MEDICAID | 64035454 | 05 | KY | MEDICAID |