Provider Demographics
NPI:1063481703
Name:ANNE ARUNDEL DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:ANNE ARUNDEL DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-384-9311
Mailing Address - Street 1:1306 CONCOURSE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-1033
Mailing Address - Country:US
Mailing Address - Phone:410-384-9311
Mailing Address - Fax:410-384-9433
Practice Address - Street 1:1306 CONCOURSE DR STE 201
Practice Address - Street 2:
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090
Practice Address - Country:US
Practice Address - Phone:443-351-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD348331201Medicaid
MD348331201Medicaid