Basic Information
| Provider Information | |||||||||
| NPI: | 1861486060 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUGMON | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1838 GREENE TREE RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106029262 | ||||||||
| FaxNumber: | 4106029276 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 N CALVERT ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212182867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103665600 | ||||||||
| FaxNumber: | 4108894952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 08/30/2010 | ||||||||
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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 | D0017225 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 968391700 | 05 | MD | MEDICAID |