Provider Demographics
NPI:1346297868
Name:MARYLAND MOBILE ANESTHESIA SERVICES INC
Entity Type:Organization
Organization Name:MARYLAND MOBILE ANESTHESIA SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEKELBURG
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:410-409-8305
Mailing Address - Street 1:11202 OLD HOPKINS RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1844
Mailing Address - Country:US
Mailing Address - Phone:410-409-8305
Mailing Address - Fax:
Practice Address - Street 1:11202 OLD HOPKINS RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1844
Practice Address - Country:US
Practice Address - Phone:410-409-8305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-29
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR059251163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD232NMedicare PIN
DCG02200Medicare PIN