1184670366 NPI number — MICHAEL H GRODIN D.O.

Table of content: MICHAEL H GRODIN D.O. (NPI 1184670366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184670366 NPI number — MICHAEL H GRODIN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRODIN
Provider First Name:
MICHAEL
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1184670366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1209 YORK RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-821-9490
Provider Business Mailing Address Fax Number:
410-821-9495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1209 YORK RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-6220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-821-9490
Provider Business Practice Location Address Fax Number:
410-821-9495
Provider Enumeration Date:
05/26/2006

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: 207W00000X , with the licence number:  H0062012 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , with the licence number: 0102201638 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: DO034176 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 25MB08472300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 405458000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143192VYZ . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com