Healthcare Provider Details

I. General information

NPI: 1649591934
Provider Name (Legal Business Name): JENNIFER PETTIFORD ALEXANDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6003
  • Fax:
Mailing address:
  • Phone: 410-328-6003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101259901
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: