Healthcare Provider Details

I. General information

NPI: 1346872157
Provider Name (Legal Business Name): DR ELLEN M MONGAN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 N CHARLES ST STE 4104
BALTIMORE MD
21204-6808
US

IV. Provider business mailing address

PO BOX 5391
BALTIMORE MD
21209-0391
US

V. Phone/Fax

Practice location:
  • Phone: 410-929-4617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ELLEN MARIE MONGAN
Title or Position: PRESIDENT
Credential: MD
Phone: 410-929-4617