Healthcare Provider Details

I. General information

NPI: 1083954317
Provider Name (Legal Business Name): TIMOTHY JOSEPH MEYENBURG C.R.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2013
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST CARDIAC SURGERY ICU
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

9368 READER LN
COLUMBIA MD
21045-3922
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-5382
  • Fax:
Mailing address:
  • Phone: 410-997-0758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR176700
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR176700
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: