1336159284 NPI number — HOWARD COUNTY GASTROINTESTINAL DIAGNOSTIC CTR, 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 1336159284 NPI number — HOWARD COUNTY GASTROINTESTINAL DIAGNOSTIC CTR, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOWARD COUNTY GASTROINTESTINAL DIAGNOSTIC CTR, 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:
6
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:
1336159284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10710 CHARTER DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21044-2858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-772-7345
Provider Business Mailing Address Fax Number:
410-772-8860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10710 CHARTER DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21044-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-772-7345
Provider Business Practice Location Address Fax Number:
410-772-8860
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAILEY
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
203-609-1168

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , with the licence number:  A1342 , 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: 8362033 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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