Healthcare Provider Details

I. General information

NPI: 1194460899
Provider Name (Legal Business Name): MICHAELA CUSTIS BENDURE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

IV. Provider business mailing address

8745 FOLLOW DITCH RD
WESTOVER MD
21871-3031
US

V. Phone/Fax

Practice location:
  • Phone: 410-546-6400
  • Fax:
Mailing address:
  • Phone: 443-235-8085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA10483
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: