1366872400 NPI number — SHAWN D GIACOBBE PA-C

Table of content: SHAWN D GIACOBBE PA-C (NPI 1366872400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366872400 NPI number — SHAWN D GIACOBBE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIACOBBE
Provider First Name:
SHAWN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1366872400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8322 BELLONA AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21204-2065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-337-7900
Provider Business Mailing Address Fax Number:
410-769-8591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7505 OSLER DR STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204-7737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-337-8888
Provider Business Practice Location Address Fax Number:
410-823-4833
Provider Enumeration Date:
11/26/2013

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: 363A00000X , with the licence number:  C05261 , 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: C0005261 . This is a "MARYLAND LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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