Provider Demographics
NPI:1619605078
Name:MODERN DERMATOLOGY OF MARYLAND, LLC
Entity Type:Organization
Organization Name:MODERN DERMATOLOGY OF MARYLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LANE
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:NEIDIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-216-0993
Mailing Address - Street 1:2568A RIVA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7457
Mailing Address - Country:US
Mailing Address - Phone:410-216-0993
Mailing Address - Fax:
Practice Address - Street 1:2568A RIVA RD STE 102
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7457
Practice Address - Country:US
Practice Address - Phone:410-216-0993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-12
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty