Provider Demographics
NPI:1578743399
Name:BRUCE L REGAN, MD CHARTERED
Entity Type:Organization
Organization Name:BRUCE L REGAN, MD CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRERSIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:LINTHICUM
Authorized Official - Last Name:REGAN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:410-747-6106
Mailing Address - Street 1:405 FREDERICK RD
Mailing Address - Street 2:SUITE 263
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4645
Mailing Address - Country:US
Mailing Address - Phone:410-747-6106
Mailing Address - Fax:410-747-5601
Practice Address - Street 1:405 FREDERICK RD
Practice Address - Street 2:SUITE 263
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4645
Practice Address - Country:US
Practice Address - Phone:410-747-6106
Practice Address - Fax:410-747-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0018610261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB70462Medicare UPIN
MD6927Medicare PIN