1780673095 NPI number — DR. MATTHEW J MALTA MD

Table of content: DR. MATTHEW J MALTA MD (NPI 1780673095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780673095 NPI number — DR. MATTHEW J MALTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALTA
Provider First Name:
MATTHEW
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1780673095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13830
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-573-2477
Provider Business Mailing Address Fax Number:
410-573-2478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 HOLIDAY CT
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-7005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-573-2477
Provider Business Practice Location Address Fax Number:
410-573-2475
Provider Enumeration Date:
10/19/2005

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: 207R00000X , with the licence number:  D0051819 , 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: 0001 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 483902100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 998491 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201230000 . This is a "FEDERAL WORKMANS COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33305 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 08344 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5994553 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54684902 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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