1235587874 NPI number — MARYLAND INSTITUTE FOR PELVIC NEURO SCIENCE LLC

Table of content: (NPI 1528143104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235587874 NPI number — MARYLAND INSTITUTE FOR PELVIC NEURO SCIENCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND INSTITUTE FOR PELVIC NEURO SCIENCE 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:
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Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1235587874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1447 YORK ROAD
Provider Second Line Business Mailing Address:
SUITE 406
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-343-3002
Provider Business Mailing Address Fax Number:
410-823-0015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1447 YORK ROAD
Provider Second Line Business Practice Location Address:
SUITE 406
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-6017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-343-3001
Provider Business Practice Location Address Fax Number:
410-823-0015
Provider Enumeration Date:
05/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-343-3001

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2088F0040X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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