Healthcare Provider Details

I. General information

NPI: 1346297868
Provider Name (Legal Business Name): MARYLAND MOBILE ANESTHESIA SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2006
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11202 OLD HOPKINS RD
CLARKSVILLE MD
21029-1844
US

IV. Provider business mailing address

11202 OLD HOPKINS RD
CLARKSVILLE MD
21029-1844
US

V. Phone/Fax

Practice location:
  • Phone: 410-409-8305
  • Fax:
Mailing address:
  • Phone: 410-409-8305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR059251
License Number StateMD

VIII. Authorized Official

Name: MR. GLENN R. MEKELBURG
Title or Position: DIRECTOR
Credential: CRNA
Phone: 410-409-8305