Provider Demographics
NPI:1871600379
Name:CHISMARICH, MARY BETH (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:CHISMARICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:BANGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE: 6006-B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6299
Mailing Address - Fax:314-251-4450
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE: 6006-B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6299
Practice Address - Fax:314-251-4450
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157483208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH35188Medicare UPIN