Basic Information
Provider Information | |||||||||
NPI: | 1841415205 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FILER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 630354 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212630354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3014982922 | ||||||||
FaxNumber: | 3014983074 | ||||||||
Practice Location | |||||||||
Address1: | 10425 AUDIE LANE | ||||||||
Address2: |   | ||||||||
City: | LA PLATA | ||||||||
State: | MD | ||||||||
PostalCode: | 20646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3014982922 | ||||||||
FaxNumber: | 3014983074 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2007 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | 0110438 | MD | Y |   | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic |   |
ID Information
ID | Type | State | Issuer | Description | 0001 | 01 | DC | BCBS-DC INDIVIDUAL | OTHER | 6434460 | 01 | MD | BCBS-MD INDIVIDUAL # | OTHER |