Healthcare Provider Details

I. General information

NPI: 1053304329
Provider Name (Legal Business Name): JEREMY PAUL WEINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD POB #100
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

2400 VELVET RIDGE DR
OWINGS MILLS MD
21117-3030
US

V. Phone/Fax

Practice location:
  • Phone: 410-323-9210
  • Fax: 410-323-9525
Mailing address:
  • Phone: 410-323-9210
  • Fax: 410-323-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD0032984
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: