Basic Information
| Provider Information | |||||||||
| NPI: | 1326039132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA PULMONARY ASSOC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAST CARROLL ST | ||||||||
| Address2: | PRMC STATION #379 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437722 | ||||||||
| FaxNumber: | 4105437725 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 EAST CARROLL ST | ||||||||
| Address2: | PRMC STATION #379 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437722 | ||||||||
| FaxNumber: | 4105437725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NAGEL | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4105437722 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 229675 | 01 | MAMSI | OTHER | CA8835 | 01 | RAILROAD MEDICARE | OTHER | 0000631802 | 01 | DE | MEDICAL ASSISTANCE | OTHER | 1503877 | 01 | UNITED MINE WORKERS | OTHER | E601 | 01 | BLUE SHIELD NATL CAPITAL | OTHER | KU52PE | 01 | MD | BLUE CROSS BLUE SHIELD | OTHER |