Basic Information
| Provider Information | |||||||||
| NPI: | 1063493609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINE | ||||||||
| FirstName: | CASPER | ||||||||
| MiddleName: | EZRA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 300 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016628119 | ||||||||
| FaxNumber: | 3016960985 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016628119 | ||||||||
| FaxNumber: | 3016960985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D16428 | MD | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 110047911 | 01 | MD | MEDICARE RAILROAD | OTHER | 252321300 | 05 | MD | MEDICAID | 1063493609 | 01 | MD | MEDICAID NPI | OTHER |