1861486060 NPI number — DR. MARC A MUGMON M.D.

Table of content: DR. MARC A MUGMON M.D. (NPI 1861486060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861486060 NPI number — DR. MARC A MUGMON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUGMON
Provider First Name:
MARC
Provider Middle Name:
A
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:
1861486060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1838 GREENE TREE RD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-602-9262
Provider Business Mailing Address Fax Number:
410-602-9276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 N CALVERT ST
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218-2867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-366-5600
Provider Business Practice Location Address Fax Number:
410-889-4952
Provider Enumeration Date:
09/02/2005

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: 207RC0000X , with the licence number:  D0017225 , 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: 968391700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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