Provider Demographics
NPI:1033391081
Name:ELLICOTT CITY PRIMARY CARE MEDICINE PA
Entity Type:Organization
Organization Name:ELLICOTT CITY PRIMARY CARE MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SHEEHAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:410-465-1090
Mailing Address - Street 1:10298B BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3670
Mailing Address - Country:US
Mailing Address - Phone:410-465-1091
Mailing Address - Fax:410-465-8129
Practice Address - Street 1:10298B BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3670
Practice Address - Country:US
Practice Address - Phone:410-465-1091
Practice Address - Fax:410-465-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-02
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0028246207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORGANIZATIONAL NPIOther1033391081
MDKK82Medicare PIN