Provider Demographics
NPI:1871027326
Name:EBBERT, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EBBERT
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 1:1823 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-9268
Mailing Address - Country:US
Mailing Address - Phone:304-694-6688
Mailing Address - Fax:
Practice Address - Street 1:5051 GREENSPRING AVE STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4357
Practice Address - Country:US
Practice Address - Phone:410-601-9515
Practice Address - Fax:410-601-1910
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDH918792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program