Provider Demographics
NPI: | 1750326989 |
---|---|
Name: | DAVIS, MICHAEL |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | |
Last Name: | DAVIS |
Suffix: | |
Gender: | M |
Credentials: | |
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 631479 |
Mailing Address - Street 2: | |
Mailing Address - City: | BALTIMORE |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21263-1479 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 301-293-0232 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 251 E ANTIETAM ST |
Practice Address - Street 2: | |
Practice Address - City: | HAGERSTOWN |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21740-5724 |
Practice Address - Country: | US |
Practice Address - Phone: | 240-313-9500 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-19 |
Last Update Date: | 2019-03-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
363AM0700X | ||
MD | C0002285 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 45160100 | Medicaid | |
MD | P25116 | Medicare UPIN | |
MD | 45160100 | Medicaid | |
MD | 613L | Medicare ID - Type Unspecified | MEDICARE GRP # |