Healthcare Provider Details

I. General information

NPI: 1760649958
Provider Name (Legal Business Name): BAY AREA PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 LOG CANOE CIR SUITE E
STEVENSVILLE MD
21666-2149
US

IV. Provider business mailing address

165 LOG CANOE CIR SUITE E
STEVENSVILLE MD
21666-2149
US

V. Phone/Fax

Practice location:
  • Phone: 410-643-1000
  • Fax: 410-643-5200
Mailing address:
  • Phone: 410-643-1000
  • Fax: 410-643-5200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0041579
License Number StateMD

VIII. Authorized Official

Name: DR. DEMETRIOS JAMES KALLIONGIS
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 410-643-2275