Basic Information
| Provider Information | |||||||||
| NPI: | 1306021076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANGELL | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | ELLIOT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 CROSSROADS DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437382872 | ||||||||
| FaxNumber: | 4437382713 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 MALCOLM DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211576160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108761633 | ||||||||
| FaxNumber: | 4108402100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2007 | ||||||||
| LastUpdateDate: | 08/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35098754 | OH | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | D0075473 | MD | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0065081 | 05 | OH | MEDICAID | 3362132 00 | 05 | MD | MEDICAID |