Provider Demographics
NPI:1881683522
Name:FITZGERALD, TERRENCE THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:THOMAS
Last Name:FITZGERALD
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:PO BOX 10445
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-0445
Mailing Address - Country:US
Mailing Address - Phone:410-925-1220
Mailing Address - Fax:410-601-0290
Practice Address - Street 1:516 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-4230
Practice Address - Country:US
Practice Address - Phone:410-925-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-16
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31064207P00000X, 207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD465611300Medicaid
DC0497570Medicaid
D76190Medicare UPIN