1497810378 NPI number — DR. JASON M LEE-LLACER MD

Table of content: DR. JASON M LEE-LLACER MD (NPI 1497810378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497810378 NPI number — DR. JASON M LEE-LLACER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE-LLACER
Provider First Name:
JASON
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1497810378
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64916
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-6467
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
ACUTE CARE PAVILION
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-3280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-481-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2006

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: 207R00000X , with the licence number:  D0064818 , 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: 206362 . This is a "JHHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0042 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 89550101 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145724700 . This is a "DEPT. OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 263508 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1503640 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 318699 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 412132500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7132906 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".




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