Provider Demographics
NPI:1770560617
Name:SEAGRAVES, MARY ANNETTE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNETTE
Last Name:SEAGRAVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8890 N UNION BLVD
Mailing Address - Street 2:STE 160
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7799
Mailing Address - Country:US
Mailing Address - Phone:719-365-9950
Mailing Address - Fax:719-365-9969
Practice Address - Street 1:4110 BRIARGATE PKWY STE 140
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7836
Practice Address - Country:US
Practice Address - Phone:719-364-8346
Practice Address - Fax:719-364-6488
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0028267202K00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01282672Medicaid
COCOA100219Medicare PIN
CO01282672Medicaid
COCOA109630Medicare PIN
CO01282672Medicaid