1396897799 NPI number — DR. GLYNIS MOODY MD

Table of content: DR. GLYNIS MOODY MD (NPI 1396897799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396897799 NPI number — DR. GLYNIS MOODY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOODY
Provider First Name:
GLYNIS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1396897799
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:
985 PRINCE FREDERICK BLVD STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCE FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20678-3492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-535-2005
Provider Business Mailing Address Fax Number:
410-535-4850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10845 TOWN CENTER BLVD STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNKIRK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20754-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-535-2005
Provider Business Practice Location Address Fax Number:
410-535-4850
Provider Enumeration Date:
01/17/2007

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: 207R00000X , with the licence number:  D50233 , 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: 2384434 . This is a "AETNA HMO PCP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 54413801 . This is a "CAREFIRST OF MARYLAND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7010013 . This is a "AETNA NON-HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 763260600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8126360 . This is a "MAMSI HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: C0410031 . This is a "CAREFIRST OF DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: P00161495 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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