Provider Demographics
NPI:1174578934
Name:DAMIANI, MARY ANNE (DO)
Entity type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:DAMIANI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17047 LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7227
Mailing Address - Country:US
Mailing Address - Phone:815-300-7764
Mailing Address - Fax:
Practice Address - Street 1:17047 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7227
Practice Address - Country:US
Practice Address - Phone:815-300-7764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078370207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078370Medicaid
IL110156090OtherRAILROAD MEDICARE
IL110156090Medicare PIN
IL110156090OtherRAILROAD MEDICARE