Healthcare Provider Details

I. General information

NPI: 1831780253
Provider Name (Legal Business Name): U M FDSP ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W BALTIMORE STREET FACULTY PRACTICE CLINIC 1ST FLOOR
BALTIMORE MD
21201-1510
US

IV. Provider business mailing address

650 W BALTIMORE ST STE 5201
BALTIMORE MD
21201-1510
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-7961
  • Fax: 410-706-3028
Mailing address:
  • Phone: 410-706-5806
  • Fax: 410-706-3028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ELYSE B MARKWITZ
Title or Position: DIR. OF MEDICAL CREDENTIALING & QA
Credential:
Phone: 410-706-5806