Basic Information
| Provider Information | |||||||||
| NPI: | 1760661854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDELL | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | VARYCK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1745 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215011745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017595280 | ||||||||
| FaxNumber: | 3017775630 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 THOMAS JOHNSON DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016958390 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | D36477 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 26336-1200 | 05 | MD | MEDICAID |