Basic Information
| Provider Information | |||||||||
| NPI: | 1528241171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JERROLD S. CANAKIS, MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 242 | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218110242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106419450 | ||||||||
| FaxNumber: | 4106414904 | ||||||||
| Practice Location | |||||||||
| Address1: | 10344 OLD OCEAN CITY BLVD | ||||||||
| Address2: | BLVD #1 | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106412938 | ||||||||
| FaxNumber: | 4106414904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 07/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | CANAKIS | ||||||||
| AuthorizedOfficialFirstName: | JERROLD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4106412938 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100016996 | 01 | DE | RAILROAD MEDICARE | OTHER | 100016996 | 01 | MD | RAILROAD MEDICARE | OTHER |