Basic Information
Provider Information | |||||||||
NPI: | 1295736429 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEVINE | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: | ISADORE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1111 BENFIELD BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MILLERSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 211083002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107295100 | ||||||||
FaxNumber: | 4107295156 | ||||||||
Practice Location | |||||||||
Address1: | 11055 LITTLE PATUXENT PKWY | ||||||||
Address2: | SUITE 104 | ||||||||
City: | COLUMBIA | ||||||||
State: | MD | ||||||||
PostalCode: | 210442896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107402900 | ||||||||
FaxNumber: | 4107402955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2005 | ||||||||
LastUpdateDate: | 01/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0022856 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110142478 | 01 | MD | RR MEDICARE | OTHER | 780581100 | 05 | MD |   | MEDICAID | 020550 | 01 | MD | JHHC PROVIDER NUMBER | OTHER | 0477651 | 01 | MD | AETNA CAPITATED | OTHER | 243368 | 01 | MD | MAMSI SPECIALIST | OTHER | P12725 | 01 | MD | CAREFIRST MPOS | OTHER | 3509-0004 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 1865815 | 01 | MD | CIGNA PIN | OTHER | 366910-01 | 01 | MD | CAREFIRST MD RENDERING | OTHER | 4238661 | 01 | MD | AETNA FEE FOR SERVICE | OTHER | 843368 | 01 | MD | MAMSI PRIMARY CARE | OTHER |