Healthcare Provider Details

I. General information

NPI: 1619605078
Provider Name (Legal Business Name): MODERN DERMATOLOGY OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2568A RIVA RD STE 102
ANNAPOLIS MD
21401-7457
US

IV. Provider business mailing address

2568A RIVA RD STE 102
ANNAPOLIS MD
21401-7457
US

V. Phone/Fax

Practice location:
  • Phone: 410-216-0993
  • Fax:
Mailing address:
  • Phone: 410-216-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LANE ALEXANDER NEIDIG
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 410-216-0993