Healthcare Provider Details

I. General information

NPI: 1104188424
Provider Name (Legal Business Name): ANNAPOLIS RHEUMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 DEFENSE HWY STE 200
ANNAPOLIS MD
21401-8922
US

IV. Provider business mailing address

166 DEFENSE HWY STE 200
ANNAPOLIS MD
21401-8922
US

V. Phone/Fax

Practice location:
  • Phone: 410-897-1941
  • Fax:
Mailing address:
  • Phone: 410-897-1941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: ASHOK JACOB
Title or Position: MANGING DIRECTOR
Credential: M.D.
Phone: 301-367-3235