1760587596 NPI number — DR. SAMUEL B ITSCOITZ MD

Table of content: DR. SAMUEL B ITSCOITZ MD (NPI 1760587596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760587596 NPI number — DR. SAMUEL B ITSCOITZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ITSCOITZ
Provider First Name:
SAMUEL
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1760587596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 WYMAN PARK DR
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:
21211-2803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12070 OLD LINE CTR STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALDORF
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20602-3535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-645-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2006

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: 207RC0000X , with the licence number:  D0005568 , 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: 0787143 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 24324 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 206411100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4086234 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: KA62IT . This is a "BLUE CROSS MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 58030002 . This is a "BLUE CROSS DC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 779721400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: CM6438 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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