Healthcare Provider Details

I. General information

NPI: 1427284595
Provider Name (Legal Business Name): GATEWAY PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 WESLEY DR
SALISBURY MD
21801-7130
US

IV. Provider business mailing address

1415 WESLEY DR
SALISBURY MD
21801-7130
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-7000
  • Fax: 410-912-4202
Mailing address:
  • Phone: 410-912-7000
  • Fax: 410-912-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA J GRAVES
Title or Position: OFFICE MANAGER
Credential:
Phone: 410-912-7000