Provider Demographics
NPI:1043288087
Name:JACK R LICHTENSTEIN, MD LLC
Entity Type:Organization
Organization Name:JACK R LICHTENSTEIN, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:LICHTENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-268-6910
Mailing Address - Street 1:205 RIDGELY AVE
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:410-263-6910
Mailing Address - Fax:443-433-0456
Practice Address - Street 1:205 RIDGELY AVE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-263-6910
Practice Address - Fax:443-433-0456
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACK R LICHTENSTEIN, MD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-08
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD08194207R00000X, 207RR0500X
MDD0008194207RR0500X
MDD0065841207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3304001OtherCAREFIRST
DCJ1740003OtherCAREFIRST
MD785361100Medicaid
MD785361100Medicaid
MD796MMedicare PIN