Basic Information
| Provider Information | |||||||||
| NPI: | 1205928223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILMORE | ||||||||
| FirstName: | TEDRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7141 SECURITY BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212441800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007777904 | ||||||||
| FaxNumber: | 3862586882 | ||||||||
| Practice Location | |||||||||
| Address1: | 7141 SECURITY BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212441800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007777904 | ||||||||
| FaxNumber: | 3862586882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME 98980 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 278400900 | 05 | FL | MEDICAID |