Healthcare Provider Details

I. General information

NPI: 1912120916
Provider Name (Legal Business Name): BRIGHT OAKS PEDIATRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 LAUREL BUSH RD STE H
BEL AIR MD
21015-6156
US

IV. Provider business mailing address

2111 LAUREL BUSH RD STE H
BEL AIR MD
21015-6156
US

V. Phone/Fax

Practice location:
  • Phone: 410-569-3300
  • Fax: 410-515-2027
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0045592
License Number StateMD

VIII. Authorized Official

Name: MRS. SUSAN WUNDERER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 410-569-3300