Provider Demographics
NPI:1831279165
Name:MANCOLL, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MANCOLL
Suffix:
Gender:F
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 631568
Mailing Address - Street 2:MUH 9 SOUTH
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10085 RED RUN BLVD
Practice Address - Street 2:STE 306
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4836
Practice Address - Country:US
Practice Address - Phone:410-581-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD62284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKJ68ME/64401501OtherCAREFIRST MARYLAND
MD002495300Medicaid
MDS1210007OtherCAREFIRST REGIONAL
MDS1210007OtherCAREFIRST REGIONAL
MD716LK559Medicare PIN