1740420686 NPI number — DR. MICHELLE MARJORIE HESSEN O.D.

Table of content: ELISHEVA L KADOSH NP-C (NPI 1932812633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740420686 NPI number — DR. MICHELLE MARJORIE HESSEN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HESSEN
Provider First Name:
MICHELLE
Provider Middle Name:
MARJORIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KUBANCIK
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
MARJORIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740420686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64481
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:
21264-4481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-955-5080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N WOLFE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21287-0005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-955-5080
Provider Business Practice Location Address Fax Number:
410-614-1670
Provider Enumeration Date:
03/05/2009

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: 152W00000X , with the licence number:  TA2108 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: OEG002283 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 419434900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00783551 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1024004990001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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