MEDICARE: ELLICOTT CITY PRIMARY CARE MEDICINE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	D0028246	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ORGANIZATIONAL NPI	OTHER		1033391081

General Provider Information

NPI Number	:	1033391081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLICOTT CITY PRIMARY CARE MEDICINE PA

Provider Business Mailing Address
First Line	:	10298B BALTIMORE NATIONAL PIKE
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3670
Country	:	US
Telephone Number	:	410-465-1091
Fax Number	:	410-465-8129

Provider Business Practice Location Address
First Line	:	10298B BALTIMORE NATIONAL PIKE
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3670
Country	:	US
Telephone Number	:	410-465-1091
Fax Number	:	410-465-8129

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES EDWARD SHEEHAN III
Credential	:	M.D.
Telephone Number	:	410-465-1090

Provider Enumeration Date	:	12/02/2007
Last Update Date	:	09/17/2012

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Practice Location Address:

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21042-3670

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1164966735 — PARMAR PRIMARY CARE MEDICINE LLC
Practice Location Address:

10298B BALTIMORE NATIONAL PIKE
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Practice Fax: 410-465-8129

Directions to “ELLICOTT CITY PRIMARY CARE MEDICINE PA ” Practice Location

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