Provider Demographics
NPI:1679896252
Name:CHARLES S. SAMORODIN MD, PA
Entity Type:Organization
Organization Name:CHARLES S. SAMORODIN MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:SAMORODIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-628-2266
Mailing Address - Street 1:54 SCOTT ADAM ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-3292
Mailing Address - Country:US
Mailing Address - Phone:410-628-2266
Mailing Address - Fax:410-628-2653
Practice Address - Street 1:54 SCOTT ADAM RD
Practice Address - Street 2:SUITE 201
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-3292
Practice Address - Country:US
Practice Address - Phone:410-628-2266
Practice Address - Fax:410-628-2653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD12936207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD051531100Medicaid
MD051531100Medicaid
B67190Medicare UPIN