Healthcare Provider Details

I. General information

NPI: 1457642068
Provider Name (Legal Business Name): MARYLAND SKIN CARE CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 E PULASKI HWY 125
ELKTON MD
21921-6497
US

IV. Provider business mailing address

216 E PULASKI HWY 125
ELKTON MD
21921-6497
US

V. Phone/Fax

Practice location:
  • Phone: 443-485-6614
  • Fax: 410-286-1700
Mailing address:
  • Phone: 443-485-6614
  • Fax: 410-286-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD0067588
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0067588
License Number StateMD

VIII. Authorized Official

Name: DR. JAGADEESH S V KUMAR
Title or Position: SOLE MEMBER
Credential: MD
Phone: 602-930-0509