Healthcare Provider Details

I. General information

NPI: 1245028976
Provider Name (Legal Business Name): ANDARGACHEW EJIGU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SAINT PAUL ST
BALTIMORE MD
21202-2123
US

IV. Provider business mailing address

345 SAINT PAUL ST
BALTIMORE MD
21202-2123
US

V. Phone/Fax

Practice location:
  • Phone: 207-835-1111
  • Fax:
Mailing address:
  • Phone: 207-835-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR231687
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR231687
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: