Healthcare Provider Details

I. General information

NPI: 1083855092
Provider Name (Legal Business Name): MARYLAND DIAGNOSTIC AND THERAPEUTIC ENDO CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2009
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 RIDGELY AVE SUITE 105
ANNAPOLIS MD
21401-1081
US

IV. Provider business mailing address

621 RIDGELY AVE SUITE 105
ANNAPOLIS MD
21401-1081
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-3636
  • Fax: 410-224-6971
Mailing address:
  • Phone: 410-224-3636
  • Fax: 410-224-6971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL S. EPSTEIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-266-1588