1467643866 NPI number — ELLEN MARCINIAK MD

Table of content: ELLEN MARCINIAK MD (NPI 1467643866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467643866 NPI number — ELLEN MARCINIAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARCINIAK
Provider First Name:
ELLEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467643866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64442
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-328-1512
Provider Business Mailing Address Fax Number:
410-328-0177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 S GREENE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-1544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-328-1512
Provider Business Practice Location Address Fax Number:
410-328-0177
Provider Enumeration Date:
08/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  57.013558 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: D74874 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 494910200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: S062-0554 . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".