Provider Demographics
NPI:1861418162
Name:STOWE, MARY WASSELL (MD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:WASSELL
Last Name:STOWE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-302-8200
Mailing Address - Fax:704-302-8201
Practice Address - Street 1:3030 RANDOLPH RD
Practice Address - Street 2:SUITE 200, MMG MUSEUM
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1368
Practice Address - Country:US
Practice Address - Phone:704-302-8200
Practice Address - Fax:704-302-8201
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56501207R00000X
NC9400152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00152Medicaid
NC1861418162Medicaid
NC8980209Medicaid
NC2199533HMedicare PIN
NC8980209Medicaid
NC2199533JMedicare PIN