Healthcare Provider Details

I. General information

NPI: 1578546065
Provider Name (Legal Business Name): MATTHEW DANIEL SEDGLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 OLD ANNAPOLIS RD SUITE 220
ELLICOTT CITY MD
21042-6314
US

IV. Provider business mailing address

9501 OLD ANNAPOLIS RD SUITE 220
ELLICOTT CITY MD
21042-6314
US

V. Phone/Fax

Practice location:
  • Phone: 410-772-2000
  • Fax: 410-772-2039
Mailing address:
  • Phone: 410-772-2000
  • Fax: 410-772-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43792
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberD0073797
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: