Provider Demographics
NPI:1821043266
Name:MELVILLE, KRAIG A
Entity Type:Individual
Prefix:
First Name:KRAIG
Middle Name:A
Last Name:MELVILLE
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 1:1030 DOUBLE GATE RD
Mailing Address - Street 2:
Mailing Address - City:DAVIDSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21035-1807
Mailing Address - Country:US
Mailing Address - Phone:410-798-8213
Mailing Address - Fax:410-798-8534
Practice Address - Street 1:900 S CATON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:410-368-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050708207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD543213800Medicaid
MDG09734Medicare UPIN
MD584L-89IIMedicare ID - Type Unspecified