Provider Demographics
NPI:1093860553
Name:ANTIETAM NEUROLOGY CENTER, PA
Entity Type:Organization
Organization Name:ANTIETAM NEUROLOGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEHRULLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-797-1900
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD STE 227
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6727
Mailing Address - Country:US
Mailing Address - Phone:301-797-1900
Mailing Address - Fax:301-797-2238
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 227
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6727
Practice Address - Country:US
Practice Address - Phone:301-797-1900
Practice Address - Fax:301-797-2238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0022136174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4237013 00Medicaid
MDC34034Medicare UPIN
MD4237013 00Medicaid
MDS855Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID