Healthcare Provider Details

I. General information

NPI: 1104891076
Provider Name (Legal Business Name): PULMONARY DISEASE AND CRITICAL CARE ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 CHARTER DRIVE SUITE 310
COLUMBIA MD
21044-3260
US

IV. Provider business mailing address

10710 CHARTER DRIVE SUITE 310
COLUMBIA MD
21044-3260
US

V. Phone/Fax

Practice location:
  • Phone: 410-997-5944
  • Fax: 410-997-1720
Mailing address:
  • Phone: 410-997-5944
  • Fax: 410-997-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: MS. LAURA NYANJOM
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 410-997-5944