Healthcare Provider Details

I. General information

NPI: 1982558904
Provider Name (Legal Business Name): MARYLAND ONCOLOGY HEMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 THOMAS JOHNSON DR STE 250
FREDERICK MD
21702-4972
US

IV. Provider business mailing address

11720 BELTSVILLE DR STE 300
BELTSVILLE MD
20705-3119
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-6777
  • Fax: 301-695-4852
Mailing address:
  • Phone: 240-223-1869
  • Fax:

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: KYLE BLACK
Title or Position: MANAGED CARE DIRECTOR
Credential:
Phone: 610-442-2026