Healthcare Provider Details

I. General information

NPI: 1710041769
Provider Name (Legal Business Name): IVAN Z GORELIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7141 SECURITY BLVD KAISER PERMANENTE WOODLAWN MEDICAL CENTER
BALTIMORE MD
21244-1811
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 443-663-6000
  • Fax:
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD18167
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: