Provider Demographics
NPI:1780789396
Name:STANG, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:STANG
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 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS RD
Practice Address - Street 2:SUITE 160
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4515
Practice Address - Country:US
Practice Address - Phone:410-583-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0019926207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD761L738DMedicare PIN
MD179807YVZMedicare PIN
MD329936YWV2Medicare PIN
MD179807ZDDBMedicare PIN
MD301091100Medicaid
MD761L738DMedicare PIN
MD75859901OtherBLUE SHIELD
D73729Medicare UPIN