Healthcare Provider Details

I. General information

NPI: 1366739179
Provider Name (Legal Business Name): MARYLAND HEALING WATERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 LARRYVALE RD
BALTIMORE MD
21209-3206
US

IV. Provider business mailing address

2506 LARRYVALE RD
BALTIMORE MD
21209-3206
US

V. Phone/Fax

Practice location:
  • Phone: 410-761-7901
  • Fax: 410-761-1031
Mailing address:
  • Phone: 410-761-7901
  • Fax: 410-761-1031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD25559
License Number StateMD

VIII. Authorized Official

Name: DR. LAWRENCE VIDAVER
Title or Position: PHYSICIAN
Credential: MD
Phone: 410-761-7901