Healthcare Provider Details

I. General information

NPI: 1396803847
Provider Name (Legal Business Name): IRA GUBERNICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 S NORTH PT RD STE 101
BALTIMORE MD
21224
US

IV. Provider business mailing address

1050 S NORTH PT RD STE 101
BALTIMORE MD
21224
US

V. Phone/Fax

Practice location:
  • Phone: 410-282-7600
  • Fax: 410-282-4802
Mailing address:
  • Phone: 410-282-7600
  • Fax: 410-282-4802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD38112
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: