1104951292 NPI number — DR. JEREMY ANDREW MICHALKE M.D.

Table of content: DR. JEREMY ANDREW MICHALKE M.D. (NPI 1104951292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104951292 NPI number — DR. JEREMY ANDREW MICHALKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICHALKE
Provider First Name:
JEREMY
Provider Middle Name:
ANDREW
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:
1104951292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 E JEFFERSON ST
Provider Second Line Business Mailing Address:
KAISER PERMANENTE MEDICARE ENROLLMENT
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-4908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-816-2424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6701 N CHARLES ST
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE GREATER BALTIMORE MEDICAL CENTER
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204-6808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-849-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2007

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: 207P00000X , with the licence number:  C7-0002946 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: D66035 , 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: 412740400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 451601000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00418710 . This is a "RAILROAD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".