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

Table of content: MS. MARY BETH LENNOX MENDOZA PA-C (NPI 1194786186)

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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