Basic Information
| Provider Information | |||||||||
| NPI: | 1568997617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVERSANO | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6565 N CHARLES ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212045805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438493760 | ||||||||
| FaxNumber: | 4438498138 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438498046 | ||||||||
| FaxNumber: | 4438498057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2017 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MD | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | H0093511 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 01 | PROVIDER | OTHER | 390200000X | 05 | MD | MEDICAID |