Healthcare Provider Details

I. General information

NPI: 1932670122
Provider Name (Legal Business Name): MURUGESAN MANIVASAGAM CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UPPER CHESAPEAKE DR
BEL AIR MD
21014-4324
US

IV. Provider business mailing address

2720 SUNNYSIDE LN
ELLICOTT CITY MD
21043-3686
US

V. Phone/Fax

Practice location:
  • Phone: 443-643-1500
  • Fax: 443-643-1505
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR184344
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR184344
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberR184344
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: