Provider Demographics
NPI:1083621676
Name:MEDALIE, G ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:G
Middle Name:ROBERT
Last Name:MEDALIE
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 1:6535 N CHARLES STREET
Mailing Address - Street 2:SUITE 325
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-5824
Mailing Address - Country:US
Mailing Address - Phone:410-321-9701
Mailing Address - Fax:410-321-0845
Practice Address - Street 1:6535 N CHARLES STREET
Practice Address - Street 2:SUITE 325
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-5824
Practice Address - Country:US
Practice Address - Phone:410-321-9701
Practice Address - Fax:410-321-0845
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0021398207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD060057954OtherRAILROAD MEDICARE
MD138731600Medicaid
MD138731600Medicaid
MD842L088EMedicare PIN