1275553620 NPI number — DR. MICHAEL G RADLEY M.D.

Table of content: DR. MICHAEL G RADLEY M.D. (NPI 1275553620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275553620 NPI number — DR. MICHAEL G RADLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RADLEY
Provider First Name:
MICHAEL
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
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:
1275553620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20310 COTTONWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21742-4020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-733-4232
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 WESTERN MARYLAND PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21740-5146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-797-9240
Provider Business Practice Location Address Fax Number:
301-797-4119
Provider Enumeration Date:
07/20/2006

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: 207T00000X , with the licence number:  D0045936 , 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: 966246 . This is a "PA BLUE SHIELD PA LOC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: W2660003 . This is a "MD BLUE SHIELD REGIONAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 53220504 . This is a "MD BLUE SHIELD TRADITIONA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 140005761 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 436164 . This is a "PA BLUE SHIELD MD LOC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 597381300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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