Basic Information
| Provider Information | |||||||||
| NPI: | 1760587596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ITSCOITZ | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 WYMAN PARK DR | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212112803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12070 OLD LINE CTR STE 303 | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016455100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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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 | 207RC0000X | D0005568 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0787143 | 01 | AETNA | OTHER | 24324 | 01 | MAMSI | OTHER | 206411100 | 05 | MD | MEDICAID | 4086234 | 01 | UNITED HEALTH CARE | OTHER | KA62IT | 01 | BLUE CROSS MD | OTHER | 58030002 | 01 | BLUE CROSS DC | OTHER | 779721400 | 05 | MD | MEDICAID | CM6438 | 01 | RAILROAD MEDICARE | OTHER |