1740219674 NPI number — ERROL A PHILLIP MD PA

Table of content: (NPI 1740219674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740219674 NPI number — ERROL A PHILLIP MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERROL A PHILLIP MD PA
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:
1740219674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64713
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:
21264-4713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-6538
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2002 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 670
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-481-1150
Provider Business Practice Location Address Fax Number:
410-224-0065
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIP
Authorized Official First Name:
ERROL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
443-481-1150

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D0009453 , 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: 0P73EA . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6307 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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