Basic Information
| Provider Information | |||||||||
| NPI: | 1649317264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHMAN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | JUDAH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 FREDERICK AVENUE | ||||||||
| Address2: | NA | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102331400 | ||||||||
| FaxNumber: | 4102335583 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 FREDERICK AVENUE | ||||||||
| Address2: | NA | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212293618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102331400 | ||||||||
| FaxNumber: | 4102335583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 2084A0401X | D0038913 | MD | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084A0401X | MD19227 | DC | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0800X | MD19227 | DC | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | D0038913 | MD | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | D0038913 | MD | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0802X | MD19227 | DC | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0804X | D0038913 | MD | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | MD19227 | DC | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | BF2501725 XF2501725 | 01 | CONTROLLED SUBSTANCE REG | OTHER |