Healthcare Provider Details

I. General information

NPI: 1982700787
Provider Name (Legal Business Name): MUMTAZ B. MEHOOB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8455 BALTIMORE NATIONAL PIKE SUITE C
ELLICOTT CITY MD
21043-4208
US

IV. Provider business mailing address

8455 BALTIMORE NATIONAL PIKE SUITE C
ELLICOTT CITY MD
21043-4208
US

V. Phone/Fax

Practice location:
  • Phone: 410-465-6300
  • Fax: 410-465-1943
Mailing address:
  • Phone: 410-465-6300
  • Fax: 410-465-1943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MUMTAZ BANU MEHBOOB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-465-6300