Basic Information
| Provider Information | |||||||||
| NPI: | 1467539676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 OCEAN GTWY | ||||||||
| Address2: | STE 4 | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106908181 | ||||||||
| FaxNumber: | 4106908185 | ||||||||
| Practice Location | |||||||||
| Address1: | 29520 CANVASBACK DR | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108225007 | ||||||||
| FaxNumber: | 4108225569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/28/2017 | ||||||||
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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 | 2084P0804X | D0066569 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 609550002 | 05 | MD | MEDICAID | 259147-000 | 01 | MD | MAGELLAN | OTHER | 346646 | 01 | MD | MHN | OTHER | LM49EA | 01 | MD | CAREFIRST BCBS | OTHER | 609550004 | 05 | MD | MEDICAID | 517251 | 01 | MD | UBH | OTHER | 522156095 | 01 | MD | COMMERCIAL INSURANCE | OTHER | R968 | 01 | MD | CAREFIRST BCBS-FEDERAL | OTHER | 609550001 | 05 | MD | MEDICAID |