Healthcare Provider Details

I. General information

NPI: 1942499181
Provider Name (Legal Business Name): ELIAS K SHAYA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD RMB SUITE 406
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

5601 LOCH RAVEN BLVD RMB SUITE 406
BALTIMORE MD
21239
US

V. Phone/Fax

Practice location:
  • Phone: 410-532-4540
  • Fax:
Mailing address:
  • Phone: 410-532-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0038957
License Number StateMD

VIII. Authorized Official

Name: MRS. KIMBLEY IEASHA GREEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 410-532-4540