Provider Demographics
NPI:1811908817
Name:JIN GU MD PA
Entity type:Organization
Organization Name:JIN GU MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-828-8005
Mailing Address - Street 1:7505 OSLER DR
Mailing Address - Street 2:SUITE 312
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7736
Mailing Address - Country:US
Mailing Address - Phone:410-828-8005
Mailing Address - Fax:410-828-0537
Practice Address - Street 1:7505 OSLER DR
Practice Address - Street 2:SUITE 312
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7736
Practice Address - Country:US
Practice Address - Phone:410-828-8005
Practice Address - Fax:410-828-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD56623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
60924901OtherBSMD PIN #
F376OtherBSDC GROUP #
5004985OtherCGNA PIN #
7592182OtherANHM GROUP #
MD004301000Medicaid
0928824OtherKEYS GROUP #
2504440OtherAHMO PIN #
2504440OtherAHMO GROUP #
928824OtherBSPA GROUP #
KEG4JIOtherBSMD GROUP #
7592182OtherANHM PIN #
81709OtherCOV PIN #
0001OtherBSDC PIN #
5004985OtherCGNA GROUP #
81709OtherCOV GROUP #
81709OtherCOV GROUP #
=========OtherCOMM PIN #
KEG4JIOtherBSMD GROUP #
KEG4JIOtherBSMD GROUP #
MD004301000Medicaid