Provider Demographics
NPI:1902850548
Name:KELEMEN, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:KELEMEN
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 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-790-7690
Mailing Address - Fax:410-328-8225
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-790-7690
Practice Address - Fax:410-328-8225
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45643207RC0000X
MED45643207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1902850548Medicaid
MD532666-09OtherBLUE CROSS/BLUE SHIELD
MD157011100Medicaid
DC037572100Medicaid
WV3810000258Medicaid
MD532666-09OtherBLUE CROSS/BLUE SHIELD
WV3810000258Medicaid
DE1902850548Medicaid