1962558437 NPI number — DR. JOHN ROBERT TICEHURST M.D.

Table of content: DR. JOHN ROBERT TICEHURST M.D. (NPI 1962558437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962558437 NPI number — DR. JOHN ROBERT TICEHURST M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TICEHURST
Provider First Name:
JOHN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1962558437
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4940 EASTERN AVE
Provider Second Line Business Mailing Address:
CLINICAL LABS, ROOM A102, JOHNS HOPKINS BAYVIEW MED CTR
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21224-2735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-550-0648
Provider Business Mailing Address Fax Number:
410-550-2109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7385 BALTIMORE ANNAPOLIS BLVD STE L
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-3278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-999-6421
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2007

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: 207ZP0105X , with the licence number:  D0050680 , 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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