MEDICARE: IMMUTECH-MIDATLANTIC, LLC

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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1740874627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMUTECH-MIDATLANTIC, LLC

Provider Business Mailing Address
First Line	:	1940 WINDER RD
Second Line	:
City	:	WINDSOR MILL
State	:	MD
Zip	:	21244-1729
Country	:	US
Telephone Number	:	410-215-2596
Fax Number	:

Provider Business Practice Location Address
First Line	:	1940 WINDER RD
Second Line	:
City	:	WINDSOR MILL
State	:	MD
Zip	:	21244-1729
Country	:	US
Telephone Number	:	410-215-2596
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ROBIN BUCKNER
Credential	:
Telephone Number	:	410-215-2596

Provider Enumeration Date	:	02/22/2021
Last Update Date	:	07/21/2021

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