Healthcare Provider Details

I. General information

NPI: 1265054092
Provider Name (Legal Business Name): FENAN RASSU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-735-4856
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number06832
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number06832
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: