Provider Demographics
NPI:1023143138
Name:MICHAEL R MARDINEY JR MD PA
Entity type:Organization
Organization Name:MICHAEL R MARDINEY JR MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:MARDINEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:410-461-7660
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:RIDERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21139-0490
Mailing Address - Country:US
Mailing Address - Phone:410-461-7660
Mailing Address - Fax:
Practice Address - Street 1:3105 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3348
Practice Address - Country:US
Practice Address - Phone:410-461-7660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD168PMedicare PIN
DG4346Medicare PIN
PA091542Medicare PIN
010026032Medicare PIN
DCG02310Medicare PIN