Healthcare Provider Details

I. General information

NPI: 1427342187
Provider Name (Legal Business Name): KEITH BRIAN MULL SA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2011
Last Update Date: 05/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5759 CEDAR LN
COLUMBIA MD
21044-2912
US

IV. Provider business mailing address

7401 HAWKINS DR
HANOVER MD
21076-1522
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-7890
  • Fax:
Mailing address:
  • Phone: 240-446-6936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number20282
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: