Basic Information
| Provider Information | |||||||||
| NPI: | 1881784528 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVIN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 3855 WEST CHESTER PIKE, SUITE 280 | ||||||||
| Address2: | NEMOURS DUPONT PEDIATRICS, NEWTON SQUARE | ||||||||
| City: | NEWTON SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190732304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105574800 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 10/03/2014 | ||||||||
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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 | C10006711 | DE | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD418266 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 36790 | 05 | NJ | MEDICAID | 4053079 | 05 | MD | MEDICAID | 101018361 | 05 | PA | MEDICAID |