Provider Demographics
NPI:1871848614
Name:MEDSPA M.D. LLC
Entity Type:Organization
Organization Name:MEDSPA M.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CLANZY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-446-2257
Mailing Address - Street 1:4 ESTATES COURT
Mailing Address - Street 2:SUITE 3307
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6910
Mailing Address - Country:US
Mailing Address - Phone:410-446-2257
Mailing Address - Fax:
Practice Address - Street 1:310 N EUTAW ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1807
Practice Address - Country:US
Practice Address - Phone:410-633-7721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060902208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty