1679896252 NPI number — CHARLES S. SAMORODIN MD, PA

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 1679896252 NPI number — CHARLES S. SAMORODIN MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES S. SAMORODIN MD, PA
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:
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:
1679896252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54 SCOTT ADAM ROAD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
COCKEYSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21030-3292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-628-2266
Provider Business Mailing Address Fax Number:
410-628-2653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54 SCOTT ADAM RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
COCKEYSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21030-3292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-628-2266
Provider Business Practice Location Address Fax Number:
410-628-2653
Provider Enumeration Date:
03/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SAMORODIN
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
DERMATOLOGIST
Authorized Official Telephone Number:
410-628-2266

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  D12936 , 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: 051531100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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