Basic Information
Provider Information | |||||||||
NPI: | 1811002454 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NORMAN | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ANEPOHL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5525 RESEARCH PARK DR FL 4 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212284873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9722328080 | ||||||||
FaxNumber: | 9722328099 | ||||||||
Practice Location | |||||||||
Address1: | 8000 FRANKFORD | ||||||||
Address2: | HIGHLAND SPRINGS RETIREMENT COMMUNITY | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 75252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9722328080 | ||||||||
FaxNumber: | 9722328099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2006 | ||||||||
LastUpdateDate: | 10/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | L5491 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0300X | 2020-03865 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | L5491 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 0439764 | 01 |   | EVERCARE | OTHER | 8V8101 | 01 |   | BCBS | OTHER | P00690861 | 01 |   | RR MEDICARE | OTHER |