1073511655 NPI number — MARYLAND DIAGNOSTIC SERVICES, INC.

Table of content: (NPI 1073511655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073511655 NPI number — MARYLAND DIAGNOSTIC SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND DIAGNOSTIC SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1073511655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
853 SECOND STREET PIKE
Provider Second Line Business Mailing Address:
B104
Provider Business Mailing Address City Name:
RICHBORO
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18954-1082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-354-1260
Provider Business Mailing Address Fax Number:
215-354-1266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 W RIDGELY RD
Provider Second Line Business Practice Location Address:
7B
Provider Business Practice Location Address City Name:
TIMONIUM
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-628-6046
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COREN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-354-1260

Provider Taxonomy Codes

  • Taxonomy code: 246XC2903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 246ZE0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2471S1302X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2471V0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 111523 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: H444MA . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: E509 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".