1093993990 NPI number — GARY W PHELPS CRNA INC

Table of content: (NPI 1093993990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093993990 NPI number — GARY W PHELPS CRNA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY W PHELPS CRNA 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:
1093993990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10508 CHESHAM WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21163-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-317-0020
Provider Business Mailing Address Fax Number:
301-317-0028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1838 GREENTREE ROAD
Provider Second Line Business Practice Location Address:
#180
Provider Business Practice Location Address City Name:
BALTO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-317-0020
Provider Business Practice Location Address Fax Number:
301-317-0028
Provider Enumeration Date:
02/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PHELPS
Authorized Official First Name:
GARY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
301-317-0020

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R130008 , 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: F942001 . This is a "CAREFIRST DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: NA95GW . This is a "CAREFIRST MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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