Healthcare Provider Details

I. General information

NPI: 1164011029
Provider Name (Legal Business Name): CHARLES NJIT ENOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CRAIN HWY S STE 201
GLEN BURNIE MD
21061-6438
US

IV. Provider business mailing address

1600 CRAIN HWY S STE 201
GLEN BURNIE MD
21061-6438
US

V. Phone/Fax

Practice location:
  • Phone: 410-760-0098
  • Fax:
Mailing address:
  • Phone: 240-593-5983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF12200883
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: