Healthcare Provider Details

I. General information

NPI: 1265716005
Provider Name (Legal Business Name): ERIC DOUGLASS MCCOLLUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N WOLFE ST SUITE 3015
BALTIMORE MD
21287-0011
US

IV. Provider business mailing address

200 N WOLFE ST SUITE 3015
BALTIMORE MD
21287-0011
US

V. Phone/Fax

Practice location:
  • Phone: 410-502-5791
  • Fax: 410-955-1030
Mailing address:
  • Phone: 410-502-5791
  • Fax: 410-955-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number235164
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: