Healthcare Provider Details

I. General information

NPI: 1356645063
Provider Name (Legal Business Name): ROMEO PESHKU P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CROSSROADS DR STE 312
OWINGS MILLS MD
21117-5437
US

IV. Provider business mailing address

9457 JOPPA POND RD
BALTIMORE MD
21234-1362
US

V. Phone/Fax

Practice location:
  • Phone: 410-363-6664
  • Fax:
Mailing address:
  • Phone: 410-529-3880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0004405
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC0004405
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: