1922327022 NPI number — MARY MILLER BRADEN MD

Table of content: MARY MILLER BRADEN MD (NPI 1922327022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922327022 NPI number — MARY MILLER BRADEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADEN
Provider First Name:
MARY
Provider Middle Name:
MILLER
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:
MILLER
Provider Other First Name:
MARY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922327022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1306 CONCOURSE DR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINTHICUM
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21090-1033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-384-9311
Provider Business Mailing Address Fax Number:
410-384-9433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 PRINCE FREDERICK BLVD STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCE FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20678-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-351-3376
Provider Business Practice Location Address Fax Number:
410-535-6574
Provider Enumeration Date:
05/28/2010

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: 207N00000X , with the licence number:  0101251076 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X , with the licence number: D89039 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: D89039 , 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)