1588716641 NPI number — DR. GEORGE J MAMO M.D.

Table of content: DR. GEORGE J MAMO M.D. (NPI 1588716641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588716641 NPI number — DR. GEORGE J MAMO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAMO
Provider First Name:
GEORGE
Provider Middle Name:
J
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:
1588716641
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3455 WILKENS AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21229-5213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-646-0330
Provider Business Mailing Address Fax Number:
410-644-6182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3455 WILKENS AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21229-5213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-646-0330
Provider Business Practice Location Address Fax Number:
410-644-6182
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: 208800000X , with the licence number:  D0036523 , 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: 614797 . This is a "MAMSI PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 52581804 . This is a "CAREFIRST OF MD PROV. NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 192011100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: E6120002 . This is a "BLUE CHOICE PROV. NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 20679012 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1900383 . This is a "AMERICHOICE PROV. NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: E6120002 . This is a "BCBS FEDERAL PROVIDER NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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