1891772984 NPI number — CARL JEFFREY SCHLUEDERBERG MD

Table of content: CARL JEFFREY SCHLUEDERBERG MD (NPI 1891772984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891772984 NPI number — CARL JEFFREY SCHLUEDERBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHLUEDERBERG
Provider First Name:
CARL
Provider Middle Name:
JEFFREY
Provider Name Prefix Text:
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:
1891772984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9114 PHILADELPHIA RD
Provider Second Line Business Mailing Address:
SUITE 106 - 108
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21237-4345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-918-0777
Provider Business Mailing Address Fax Number:
410-369-1707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9114 PHILADELPHIA RD
Provider Second Line Business Practice Location Address:
SUITE 106 - 108
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21237-4345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-918-0777
Provider Business Practice Location Address Fax Number:
410-369-1707
Provider Enumeration Date:
12/29/2005

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: 207Q00000X , with the licence number:  D0036951 , 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: 4140404 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100095 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 883889 . This is a "MANSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: W6560001 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".