Individual
MRS. MARY MELANIE WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1200 N EAST ST, OLNEY, IL 62450-2432
(618) 395-5222
Mailing address
PO BOX 97, OLNEY, IL 62450-0097
(618) 395-7340
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
036119328
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036119328
—
IL
Enumeration date
09/21/2005
Last updated
10/05/2009
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