1417259219 NPI number — MRS. CAROLYN DOROTHEA PHILSON BSN, RN, CDE

Table of content: MRS. CAROLYN DOROTHEA PHILSON BSN, RN, CDE (NPI 1417259219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417259219 NPI number — MRS. CAROLYN DOROTHEA PHILSON BSN, RN, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILSON
Provider First Name:
CAROLYN
Provider Middle Name:
DOROTHEA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BSN, RN, CDE
Provider Gender Code:
F

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:
1417259219
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 E JEFFERSON ST
Provider Second Line Business Mailing Address:
SUITE 4E
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-4908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-816-2424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 MERCANTILE LN
Provider Second Line Business Practice Location Address:
DIABETES SERVICES
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20774-5374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-618-5533
Provider Business Practice Location Address Fax Number:
301-618-5525
Provider Enumeration Date:
11/30/2010

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: 163WD0400X , with the licence number:  R079434 , 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)





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