Healthcare Provider Details

I. General information

NPI: 1811996291
Provider Name (Legal Business Name): CAROL A. JEROSIMICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 JENNIFER RD STE 240
ANNAPOLIS MD
21401-7995
US

IV. Provider business mailing address

170 JENNIFER RD STE 240
ANNAPOLIS MD
21401-7995
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-9000
  • Fax: 410-266-1507
Mailing address:
  • Phone: 410-571-9000
  • Fax: 410-266-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0001915
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0001915
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: