Provider Demographics
NPI:1104864032
Name:LALLY-CASSADY, DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:
Last Name:LALLY-CASSADY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:DEPT OF REHAB MEDICINE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-5597
Practice Address - Fax:410-601-9939
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD543331200Medicaid
MDCA8374OtherR/R MEDICARE GROUP #
MD250006180OtherR/R MEDICARE PIN
MDCA8374OtherR/R MEDICARE GROUP
MD250006180OtherR/R MEDICARE PROVIDER #
MD543331200Medicaid
MDS588U317Medicare PIN