Provider Demographics
NPI:1659310266
Name:DWYER, GEORGE MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MICHAEL
Last Name:DWYER
Suffix:
Gender:M
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:PO BOX 3206
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21504-3206
Mailing Address - Country:US
Mailing Address - Phone:240-964-1036
Mailing Address - Fax:240-964-1048
Practice Address - Street 1:12500 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6393
Practice Address - Country:US
Practice Address - Phone:240-964-1036
Practice Address - Fax:240-964-1048
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD433962085B0100X, 2085D0003X, 2085N0904X, 2085R0204X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD598241300Medicaid
MD598241300Medicaid
MDP00119659Medicare PIN
MDF29989Medicare UPIN
WV4027354Medicare PIN
MD831M447FMedicare PIN
MDP00318510Medicare PIN