Healthcare Provider Details

I. General information

NPI: 1770977365
Provider Name (Legal Business Name): MARY CARMELLE PHILOGENE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY CARMELLE NEPTUNE PHD

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 E MONUMENT ST
BALTIMORE MD
21205-2222
US

IV. Provider business mailing address

2041 E MONUMENT ST
BALTIMORE MD
21205-2222
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-3600
  • Fax: 410-955-0431
Mailing address:
  • Phone: 410-955-3600
  • Fax: 410-955-0431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: