Healthcare Provider Details

I. General information

NPI: 1083200794
Provider Name (Legal Business Name): ANNE ARUNDEL DERMATOLOGY AFFILIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 SCOTT ADAM RD STE 301
HUNT VALLEY MD
21030-3360
US

IV. Provider business mailing address

1306 CONCOURSE DR STE 201
LINTHICUM MD
21090-1033
US

V. Phone/Fax

Practice location:
  • Phone: 443-351-3376
  • Fax:
Mailing address:
  • Phone: 410-384-9311
  • Fax: 410-384-9433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA RUTH PETERMAN
Title or Position: MD
Credential:
Phone: 443-351-3376