Basic Information
| Provider Information | |||||||||
| NPI: | 1003912866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANNAPOLIS OB/GYN ASSOCIATES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105739530 | ||||||||
| FaxNumber: | 4105739569 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105739530 | ||||||||
| FaxNumber: | 4105739569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 10/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | LATONICK | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4105739530 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 913511100 | 05 | MD | MEDICAID |