Healthcare Provider Details

I. General information

NPI: 1528241171
Provider Name (Legal Business Name): JERROLD S. CANAKIS, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 07/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10344 OLD OCEAN CITY BLVD BLVD #1
BERLIN MD
21811-1162
US

IV. Provider business mailing address

PO BOX 242
BERLIN MD
21811-0242
US

V. Phone/Fax

Practice location:
  • Phone: 410-641-2938
  • Fax: 410-641-4904
Mailing address:
  • Phone: 410-641-9450
  • Fax: 410-641-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: JERROLD S CANAKIS
Title or Position: OWNER
Credential: M.D.
Phone: 410-641-2938