Healthcare Provider Details

I. General information

NPI: 1811124548
Provider Name (Legal Business Name): JAROSLAW JAKUB JEDRYCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2009
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR STE 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5933
  • Fax: 410-955-2445
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberD88004
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberMD446749
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD446749
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: