Basic Information
Provider Information | |||||||||
NPI: | 1962597641 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCHWARTZ | ||||||||
FirstName: | MITCHELL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 501 FAIRMOUNT AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | TOWSON | ||||||||
State: | MD | ||||||||
PostalCode: | 212865457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104947921 | ||||||||
FaxNumber: | 4109028247 | ||||||||
Practice Location | |||||||||
Address1: | 515 FAIRMOUNT AVE STE 500 | ||||||||
Address2: |   | ||||||||
City: | TOWSON | ||||||||
State: | MD | ||||||||
PostalCode: | 212865466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104941662 | ||||||||
FaxNumber: | 4104941718 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 06/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | D0044728 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | D0044728 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 342191 | 01 |   | MAMSI | OTHER | 055431600 | 05 | MD |   | MEDICAID | 1442918 | 01 |   | UNITED HEALTHCARE | OTHER | 0013 | 01 | MD | BLUE CHOICE/FEP | OTHER | 4800211 | 01 |   | UNITED HEALTHCARE MCO | OTHER | 52823601 420A | 01 | MD | BLUE SHIELD | OTHER |