Healthcare Provider Details

I. General information

NPI: 1700830114
Provider Name (Legal Business Name): MIB PARTNERSHIP LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6715 N CHARLES ST
BALTIMORE MD
21204-6822
US

IV. Provider business mailing address

PO BOX 630277
BALTIMORE MD
21263-0277
US

V. Phone/Fax

Practice location:
  • Phone: 410-296-5610
  • Fax: 410-296-2982
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM270
License Number StateMD

VIII. Authorized Official

Name: MR. MICHAEL LISSE
Title or Position: AGENT
Credential:
Phone: 301-650-9000