Basic Information
| Provider Information | |||||||||
| NPI: | 1538499884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARK | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | ROSE-MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 FAIRMOUNT AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104941379 | ||||||||
| FaxNumber: | 4104942737 | ||||||||
| Practice Location | |||||||||
| Address1: | 849 FAIRMONT AVENUE | ||||||||
| Address2: | SUITE 100A | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212862600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104941369 | ||||||||
| FaxNumber: | 4104942737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2010 | ||||||||
| LastUpdateDate: | 12/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | D0077561 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.