Basic Information
| Provider Information | |||||||||
| NPI: | 1760406482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 W REDWOOD ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672141720 | ||||||||
| FaxNumber: | 4107066976 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286897 | ||||||||
| FaxNumber: | 4103282109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | D0060640 | MD | N | Allopathic & Osteopathic Physicians | Surgery | 208800000X | D60640 | MD | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2110686 | 01 | MD | MDIPA | OTHER | 62097501 | 01 | MD | BLUE SHIELD | OTHER | 81800 | 01 | MD | GEISINGER | OTHER | 402471100 | 05 | MD | MEDICAID | 1901109 | 01 | MD | UNITED HLTHCARE | OTHER | 2339178 | 01 | MD | UNITED HLTHCARE NATIONAL | OTHER | 0087 | 01 | MD | CAREFIRST REGIONAL | OTHER | 240843 | 01 | MD | KAISER | OTHER |