Basic Information
| Provider Information | |||||||||
| NPI: | 1316983133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSTRUBIAK | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7253 AMBASSADOR RD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212442710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434361151 | ||||||||
| FaxNumber: | 4434361256 | ||||||||
| Practice Location | |||||||||
| Address1: | 7253 AMBASSADOR RD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212442710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434361151 | ||||||||
| FaxNumber: | 4434361256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D0030943 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 364211900 | 05 | MD | MEDICAID |