Provider Demographics
NPI:1144283136
Name:HENRY, MARY MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:MARTIN
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6800 STATE ROUTE 162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8521
Mailing Address - Country:US
Mailing Address - Phone:618-288-5711
Mailing Address - Fax:314-977-7615
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8521
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:314-977-7615
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1J04207ZC0500X, 207ZP0102X
IL036137460207ZC0500X, 207ZP0102X
KS04-21754207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS705958OtherKS BCBS
KS100257620AMedicaid
MO208616508Medicaid
14731031OtherKS CITY BCBS
KS100257620AMedicaid
14731031OtherKS CITY BCBS
E94263Medicare UPIN
G973015Medicare PIN
KS220018853Medicare PIN