Provider Demographics
NPI: | 1942203245 |
---|---|
Name: | JEROME, SCOTT D (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SCOTT |
Middle Name: | D |
Last Name: | JEROME |
Suffix: | |
Gender: | M |
Credentials: | DO |
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: | 410-328-5793 |
Mailing Address - Fax: | 410-328-0248 |
Practice Address - Street 1: | 410 MALCOLM DR |
Practice Address - Street 2: | STE A |
Practice Address - City: | WESTMINSTER |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21157-6160 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-876-0086 |
Practice Address - Fax: | 410-876-2946 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-05-31 |
Last Update Date: | 2008-11-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | H0039447 | 207RC0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 092691400 | Medicaid | |
MD | 521611-11 | Other | CAREFIRST - MD |
MD | S062-0326 | Other | CAREFIRST - REGIONAL |
MD | 092691400 | Medicaid | |
MD | P00630493 | Medicare PIN | |
MD | E69608 | Medicare UPIN |