Healthcare Provider Details

I. General information

NPI: 1245974617
Provider Name (Legal Business Name): KEITH LAMONT PARHAM HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2053 E MONUMENT ST STE 1
BALTIMORE MD
21205-2206
US

IV. Provider business mailing address

5413 KNELL AVE
BALTIMORE MD
21206-4335
US

V. Phone/Fax

Practice location:
  • Phone: 443-780-5559
  • Fax:
Mailing address:
  • Phone: 443-780-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number107768
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: