1033152541 NPI number — DR. SIDNEY NELSON III M.D.

Table of content: DR. SIDNEY NELSON III M.D. (NPI 1033152541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033152541 NPI number — DR. SIDNEY NELSON III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
SIDNEY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
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:
1033152541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 SABRE ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23452-7380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-222-0300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 REISTERSTOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKESVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-222-0300
Provider Business Practice Location Address Fax Number:
757-956-9806
Provider Enumeration Date:
06/13/2006

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: 208M00000X , with the licence number:  D63298 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: D63298 , 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: 409172800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA8374 . This is a "R/R MEDICARE GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: P00309490 . This is a "R/R MEDICARE PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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