Provider Demographics
NPI:1750343075
Name:FENNELL, MAUREEN C (MD)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:C
Last Name:FENNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15005 SHADY GROVE RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6340
Mailing Address - Country:US
Mailing Address - Phone:240-238-3760
Mailing Address - Fax:240-238-3765
Practice Address - Street 1:15005 SHADY GROVE RD
Practice Address - Street 2:SUITE 340
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6340
Practice Address - Country:US
Practice Address - Phone:240-238-3760
Practice Address - Fax:240-238-3765
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0044928207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0014OtherBCBS OF DC GROUP NUMBER
MD699545401Medicaid
MDH830OtherBCBS OF MD GROUP NUMBER
DC4787OtherBCBS OF DC GROUP NUMBER
MD61390003OtherBCBS OF MD INDIVIDUAL NO#
DC1912021619Medicare PIN
DC1750343075Medicare PIN
DC0014OtherBCBS OF DC GROUP NUMBER
DC4787OtherBCBS OF DC GROUP NUMBER
MDG07228Medicare UPIN