1952413080 NPI number — CHARLES COUNTY DERMATOLOGY ASSOCIATES LLC

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 1952413080 NPI number — CHARLES COUNTY DERMATOLOGY ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES COUNTY DERMATOLOGY ASSOCIATES LLC
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:
1952413080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O BOX 791011
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:
21279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-843-1600
Provider Business Mailing Address Fax Number:
301-645-4734

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4225 ALTAMONT PLACE
Provider Second Line Business Practice Location Address:
UNIT 3
Provider Business Practice Location Address City Name:
WHITE PLAINS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-843-1600
Provider Business Practice Location Address Fax Number:
301-645-4734
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERGER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
301-843-1600

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 415P . This is a "MEDICARE GROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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