Healthcare Provider Details

I. General information

NPI: 1578360517
Provider Name (Legal Business Name): UNIV OF MARYLAND OTORHINOLARYNGOLOGY HEAD & NECK SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7251 PREINKERT DRIVE 0110 LEFRAK HALL
COLLEGE PARK MD
20742-0001
US

IV. Provider business mailing address

PO BOX 64693
BALTIMORE MD
21264-4693
US

V. Phone/Fax

Practice location:
  • Phone: 301-405-4218
  • Fax: 301-314-2023
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: SHAVONDA L WILLIAMS
Title or Position: CORPORATE DIRECTOR
Credential:
Phone: 667-214-2507