1043288087 NPI number — JACK R LICHTENSTEIN, MD LLC

Table of content: (NPI 1043288087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043288087 NPI number — JACK R LICHTENSTEIN, MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACK R LICHTENSTEIN, MD LLC
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:
1043288087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 RIDGELY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-263-6910
Provider Business Mailing Address Fax Number:
443-433-0456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 RIDGELY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-263-6910
Provider Business Practice Location Address Fax Number:
443-433-0456
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LICHTENSTEIN
Authorized Official First Name:
JACK
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-268-6910

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  D08194 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: D08194 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: D0008194 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RR0500X , with the licence number: D0065841 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3304001 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: J1740003 . This is a "CAREFIRST" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 785361100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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