Healthcare Provider Details

I. General information

NPI: 1295465714
Provider Name (Legal Business Name): TAYLORED UROGYN CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/16/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2164 NOTTOWAY DRIVE
HANOVER MD
21076-1095
US

IV. Provider business mailing address

2657G ANNAPOLIS RD # 327
HANOVER MD
21076-1262
US

V. Phone/Fax

Practice location:
  • Phone: 667-274-3333
  • Fax:
Mailing address:
  • Phone: 667-274-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AISHA KHALALI TAYLOR
Title or Position: UROGYNECOLOGIC SPECIALIST
Credential: MD
Phone: 312-450-4883