Basic Information
Provider Information | |||||||||
NPI: | 1669424834 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DRESNICK/STERLING PEDIATRIC SERVICES OF MARYLAND, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6400 ATLANTIC BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322118768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9048051300 | ||||||||
FaxNumber: | 9048051456 | ||||||||
Practice Location | |||||||||
Address1: | 500 UPPER CHESAPEAKE DR | ||||||||
Address2: |   | ||||||||
City: | BEL AIR | ||||||||
State: | MD | ||||||||
PostalCode: | 210144324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4436431000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DRESNICK | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 9048051300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | S256 | 01 | DC | GROUP DC BLUE # | OTHER | KAC5SC | 01 | MD | GROUP BCBS # | OTHER | 20044981 | 01 | MD | AMERIHEALTH MERCY HLTH | OTHER |