1194786186 NPI number — MS. MARY BETH LENNOX MENDOZA PA-C

Table of content: JOANNE MARIE BACAR ANG MD (NPI 1962930586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194786186 NPI number — MS. MARY BETH LENNOX MENDOZA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
MARY BETH
Provider Middle Name:
LENNOX
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROGALSKI OR LENNOX
Provider Other First Name:
MARY BETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194786186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 CROSSROADS DR STE 306
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117-5437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-738-2872
Provider Business Mailing Address Fax Number:
443-738-2713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 MALCOLM DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21157-6160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-876-1633
Provider Business Practice Location Address Fax Number:
410-840-2100
Provider Enumeration Date:
03/29/2006

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: 363AS0400X , with the licence number:  C01911 , 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: P00250839 . This is a "R/R MEDICARE PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 970005976 . This is a "R/R MEDICARE PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: CN6601 . This is a "R/R MEDICARE GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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