Provider Demographics
NPI:1710998661
Name:G. ROBERT MEDALIE, M.D., LLC
Entity Type:Organization
Organization Name:G. ROBERT MEDALIE, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:G
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MEDALIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-321-9701
Mailing Address - Street 1:6535 N CHARLES ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-5826
Mailing Address - Country:US
Mailing Address - Phone:410-321-9701
Mailing Address - Fax:410-321-0845
Practice Address - Street 1:6535 N CHARLES ST
Practice Address - Street 2:SUITE 325
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-5826
Practice Address - Country:US
Practice Address - Phone:410-321-9701
Practice Address - Fax:410-321-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCG5485OtherMEDICARE RAILROAD