Healthcare Provider Details

I. General information

NPI: 1649322785
Provider Name (Legal Business Name): CAROL ANN NIERODA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 VAN DUSEN RD EMERGENCY ROOM
LAUREL MD
20707-9463
US

IV. Provider business mailing address

10807 HAMPTON MILL TER #130
ROCKVILLE MD
20852-5460
US

V. Phone/Fax

Practice location:
  • Phone: 301-497-7954
  • Fax:
Mailing address:
  • Phone: 301-231-7137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberD45784
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD45784
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number35.054679
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberD0045784
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier854314
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: