1699149492 NPI number — REGINALD EUGENE DEGRAFENREID JR. N.P., PMH-NP

Table of content: REGINALD EUGENE DEGRAFENREID JR. N.P., PMH-NP (NPI 1699149492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699149492 NPI number — REGINALD EUGENE DEGRAFENREID JR. N.P., PMH-NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGRAFENREID
Provider First Name:
REGINALD
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
N.P., PMH-NP
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:
1699149492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1411 GLENDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21239-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-733-2544
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1866 REISTERSTOWN RD
Provider Second Line Business Practice Location Address:
F
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208-1335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-484-5642
Provider Business Practice Location Address Fax Number:
410-484-5541
Provider Enumeration Date:
11/18/2015

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: 363LF0000X , with the licence number:  R193260 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: R193260 , 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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