Provider Demographics
NPI:1558892422
Name:EAGLESON, MACKENZIE ANNE (MD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANNE
Last Name:EAGLESON
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 1:600 N WOLFE ST
Mailing Address - Street 2:TOWER 110
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0005
Mailing Address - Country:US
Mailing Address - Phone:410-955-5000
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:TOWER 110
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5995208600000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery