Basic Information
| Provider Information | |||||||||
| NPI: | 1982636601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDSMAN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| 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: | 7815347100 | ||||||||
| FaxNumber: | 7815347358 | ||||||||
| Practice Location | |||||||||
| Address1: | 8800 WALTHER BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212349001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815347100 | ||||||||
| FaxNumber: | 7815347358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
| 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 | 207Q00000X | D0053115 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | D0053115 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 093NER-614408-04 | 01 | CAREFIRST BCBS OF MD | OTHER | KG01SE-61440804 | 01 | BCBS | OTHER | T016-0022 | 01 | CAREFIRST BCBS OF DC (CCI) | OTHER | 0943ER-614408-05 | 01 | CAREFIRST BCBS OF MD | OTHER | KG01ER-61440804 | 01 | CAREFIRST BCBS OF MD (CCI) | OTHER | P14924 | 01 | MD | BCBS OF MD | OTHER | 008203101 | 05 | MD | MEDICAID | 093NSE-614408-04 | 01 | CAREFIRST BCBS OF MD | OTHER | 0022 | 01 | DC | BCBS | OTHER | 9676-0019 | 01 | CAREFIRST BCBS OF DC | OTHER | 0403088 | 01 | EVERCARE | OTHER | 211110100 | 05 | MD | MEDICAID |