Provider Demographics
NPI:1043272610
Name:FANTRY, GEORGE T (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:T
Last Name:FANTRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8732
Mailing Address - Fax:410-328-8315
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-8732
Practice Address - Fax:410-328-8315
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD40061207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD520626-02 & 01OtherBLUE CROSS/BLUE SHIELD
DE1043272610Medicaid
MD069451700Medicaid
MD100007455Medicare PIN
MDS646Y013Medicare PIN
MD069451700Medicaid