Provider Demographics
NPI:1174724520
Name:DR. MARY WHITE PC
Entity type:Organization
Organization Name:DR. MARY WHITE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-282-4000
Mailing Address - Street 1:6451 E RIVERSIDE BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6451 E RIVERSIDE BLVD
Practice Address - Street 2:STE 104
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4421
Practice Address - Country:US
Practice Address - Phone:815-282-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004011213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDO9332OtherRAILROAD MEDICARE
ILDO9332OtherRAILROAD MEDICARE
IL207504Medicare PIN