Provider Demographics
NPI:1124101639
Name:RADOVICK, SALLY (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:RADOVICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 GREENWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-1103
Mailing Address - Country:US
Mailing Address - Phone:773-307-3353
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-502-7556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD637072080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E65512Medicare UPIN