Healthcare Provider Details

I. General information

NPI: 1396710703
Provider Name (Legal Business Name): MARYLAND ONCOLOGY HEMATOLOGY P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 CHARTER DRIVE SUITE G020
COLUMBIA MD
21044-3257
US

IV. Provider business mailing address

10710 CHARTER DRIVE SUITE G020
COLUMBIA MD
21044-3257
US

V. Phone/Fax

Practice location:
  • Phone: 410-964-2212
  • Fax: 410-964-0380
Mailing address:
  • Phone: 410-964-2212
  • Fax: 410-964-0380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS W KOUTRELAKOS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-964-2212