Basic Information
Provider Information | |||||||||
NPI: | 1518312990 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDSTAR HEALTH AT BRANDYWINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDSTAR HEALTH AT BRANDYWINE / ENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13950 BRANDYWINE RD | ||||||||
Address2: | SUITE 150 | ||||||||
City: | BRANDYWINE | ||||||||
State: | MD | ||||||||
PostalCode: | 206135815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017822220 | ||||||||
FaxNumber: | 3017822221 | ||||||||
Practice Location | |||||||||
Address1: | 13950 BRANDYWINE RD | ||||||||
Address2: | SUITE 150 | ||||||||
City: | BRANDYWINE | ||||||||
State: | MD | ||||||||
PostalCode: | 206135815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017822220 | ||||||||
FaxNumber: | 3017822221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2016 | ||||||||
LastUpdateDate: | 05/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SYLVESTER | ||||||||
AuthorizedOfficialFirstName: | JUDY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE AND BILLING | ||||||||
AuthorizedOfficialTelephone: | 3018774564 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MEDSTAR AMBULATORY SERVICES, INC, | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0123X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207YX0602X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207Y00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   |
No ID Information.