Provider Demographics
NPI:1760406482
Name:PHELAN, MICHAEL W (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:PHELAN
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 1:306 W REDWOOD ST FL 4
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1708
Mailing Address - Country:US
Mailing Address - Phone:667-214-1720
Mailing Address - Fax:410-706-6976
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6897
Practice Address - Fax:410-328-2109
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060640208600000X
MDD60640208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2110686OtherMDIPA
MD62097501OtherBLUE SHIELD
MD81800OtherGEISINGER
MD402471100Medicaid
MD1901109OtherUNITED HLTHCARE
MD2339178OtherUNITED HLTHCARE NATIONAL
MD0087OtherCAREFIRST REGIONAL
MD240843OtherKAISER
MDP00041208Medicare ID - Type UnspecifiedRAILROAD
MDG563Medicare PIN