Healthcare Provider Details

I. General information

NPI: 1568667178
Provider Name (Legal Business Name): RICHARD G MUCKERMAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA MARYLAND HEALTHCARE SYSTEM 10 NORTH GREENE STREET
BALTIMORE MD
21201-1524
US

IV. Provider business mailing address

6132 HUCKLEBERRY WAY
NEW MARKET MD
21774-6245
US

V. Phone/Fax

Practice location:
  • Phone: 800-463-6295
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR618414
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: