Healthcare Provider Details

I. General information

NPI: 1093724163
Provider Name (Legal Business Name): PLUMTREE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2006
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 S TOLLGATE RD SUITE 200
BEL AIR MD
21015-5903
US

IV. Provider business mailing address

2014 S TOLLGATE RD SUITE 200
BEL AIR MD
21015-5903
US

V. Phone/Fax

Practice location:
  • Phone: 410-569-9533
  • Fax: 410-569-1254
Mailing address:
  • Phone: 410-569-9533
  • Fax: 410-569-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberD34413
License Number StateMD

VIII. Authorized Official

Name: DR. GENEROSA CRUZ LAZOR
Title or Position: DIRECTOR
Credential: MD
Phone: 410-569-9533