Healthcare Provider Details

I. General information

NPI: 1144075904
Provider Name (Legal Business Name): MCB MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1502 PEMBERTON DR UNIT D
SALISBURY MD
21801
US

IV. Provider business mailing address

8678 SPUR LN
EASTON MD
21601
US

V. Phone/Fax

Practice location:
  • Phone: 949-696-6157
  • Fax:
Mailing address:
  • Phone: 949-696-6157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BEAVERS
Title or Position: OWNER
Credential: DO
Phone: 949-696-6157