Healthcare Provider Details

I. General information

NPI: 1093354920
Provider Name (Legal Business Name): IRINA KONSTANTINOVNA BAUM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IRINA SHIELDS RN

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3893 FORTRESS CT
HAMPSTEAD MD
21074-1790
US

IV. Provider business mailing address

3893 FORTRESS CT
HAMPSTEAD MD
21074-1790
US

V. Phone/Fax

Practice location:
  • Phone: 240-593-2301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberR211137
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberR211137
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: