1164652970 NPI number — CHARLES W DAVIS II MD LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164652970 NPI number — CHARLES W DAVIS II MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES W DAVIS II 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:
1164652970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 62440
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:
21264-2440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-625-5050
Provider Business Mailing Address Fax Number:
410-766-1404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 OAK MANOR DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-5548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-625-5050
Provider Business Practice Location Address Fax Number:
410-766-1404
Provider Enumeration Date:
07/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
W
Authorized Official Title or Position:
SOLE MANAGER
Authorized Official Telephone Number:
410-335-0008

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 159276 . This is a "MEDICARE PART B" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DCK7CW . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DP4271 . This is a "RAILROAD MEDICARE GROUP PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: Q647 . This is a "CAREFIRST" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 417933100 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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