Healthcare Provider Details

I. General information

NPI: 1609835404
Provider Name (Legal Business Name): EDWARD LELAND BIRD MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 HOSPITAL DR SUITE 204
BALTIMORE MD
21237-4373
US

IV. Provider business mailing address

500 FRANKLIN AVE
ESSEX MD
21221-6719
US

V. Phone/Fax

Practice location:
  • Phone: 443-559-5063
  • Fax: 443-559-5078
Mailing address:
  • Phone: 410-574-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC01302
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: