Healthcare Provider Details

I. General information

NPI: 1558508887
Provider Name (Legal Business Name): ALEX MARK WURM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 THOMAS JOHNSON DR
FREDERICK MD
21702-4679
US

IV. Provider business mailing address

400 W 7TH ST
FREDERICK MD
21701-4506
US

V. Phone/Fax

Practice location:
  • Phone: 240-215-6310
  • Fax:
Mailing address:
  • Phone: 240-215-6310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0069210
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA103180
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberD0069210
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: