Healthcare Provider Details

I. General information

NPI: 1346417912
Provider Name (Legal Business Name): MATILDA NANA AMBA HAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SAINT PAUL PL POB 718
BALTIMORE MD
21202-2102
US

IV. Provider business mailing address

301 SAINT PAUL PL MEDICAL STAFF OFFICE
BALTIMORE MD
21202-2102
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9356
  • Fax: 410-783-5884
Mailing address:
  • Phone: 410-659-2802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD0078377
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: